Non-pharmacological interventions to improve mental health outcomes among female carers of people living with a neurological condition: a systematic review.

PURPOSE: This systematic review aims to examine the effectiveness of non-pharmacological interventions for improving mental health outcomes among female carers of people living with a neurological condition. MATERIALS AND METHODS: A narrative synthesis of English-language randomized controlled trials was undertaken. RESULTS: 18 unique studies were included. Intervention components that were found to have improved mental health outcomes were: delivered in person, to groups, on an intermittent schedule with ≥10 sessions; had a duration between 3-6 months; and were facilitated by research staff or allied health professionals. As the review had few robust studies, results of mental health outcomes reported in studies assessed as low risk of bias were highlighted in the review. Psychoeducation interventions, cognitive behavioural interventions, and support group interventions were found to improve depression. Psychoeducation interventions were also found to improve burden. CONCLUSIONS: There is a clear need for adequately powered, high-quality randomised controlled trials to determine the effectiveness of non-pharmacological interventions for female carers of people living with a neurological condition.

Female carers experience worse mental health and well-being outcomes and are at a higher risk of developing chronic health issues compared to their male counterparts.This review identified only very few, generally small, randomised controlled trials of non-pharmacological interventions in female carers of patients with neurological conditions.Interventions that provide psychoeducation, are group-based, face-to-face, and have an intervention duration between >3 months and <6 months, may be successful in improving some mental health outcomes, such as depression and coping.

Giri-nya-la-nha (talk together) to explore acceptability of targeted smoking cessation resources with Australian Aboriginal women.

OBJECTIVES: To engage with health providers and Aboriginal women to understand what educational resources they want and need to support quit smoking attempts during pregnancy in order to develop a comprehensive evidence-based intervention. STUDY DESIGN: Resources were developed in partnership with Aboriginal people, communities and academics with the aim to be inclusive of diverse communities. We then recruited Aboriginal women of various ages for yarning circles (focus groups) held in three Australian states to explore the acceptability of the resources and seeking further guidance as to the needs of Aboriginal women to support smoking cessation during pregnancy. METHODS: Yarning circles were recorded and transcribed, and data were analysed independently by two researchers. Responses were coded using predetermined themes and further general inductive analysis for emergent themes. RESULTS: Twenty-four Aboriginal women reflected on the resources they included: one pregnant woman, 15 mothers and eight elders. Predetermined themes of attraction, comprehension, cultural acceptability, graphics and layout, persuasion and self-efficacy were explored. Women suggested the following: resources need to be visually attractive and interactive to enhance self-efficacy; additional scientific content on health consequences of smoking and combining with non-pharmacological approaches to quitting. CONCLUSION: Indigenous peoples prefer culturally targeted messages. However, developing effective Aboriginal health promotion requires more than a 'culturally appropriate' adaptation of mainstream resources. Consideration needs to be given to the diversity of Aboriginal communities when developing effective, evidence-based interventions. Aboriginal women are calling for innovative and interactive resources that enhance self-efficacy; the use of videos to explain medical and informational brochure content is well received. Requests for non-pharmacological cessation options were reported in New South Wales and Queensland and should be further explored.

Wula (Voices) of Aboriginal women on barriers to accepting smoking cessation support during pregnancy: Findings from a qualitative study.

AIM: To gather Aboriginal women's stories of smoking and becoming pregnant to identify the barriers in accepting smoking cessation support during pregnancy. METHODS: Qualitative data were collected through use of yarning methodology between August 2015 and January 2016 by an Aboriginal Researcher with experience in social and community services. A short on-line survey was used to collect quantitative data. Interviews only recorded the therapeutic yarning process, which ranged from 9 to 45min duration, averaging 30min. Audio-recorded interviews were transcribed and independently coded. A general inductive analysis was used to determine emergent themes. RESULTS: Twenty Aboriginal women between 17-38 years of age, who were pregnant or recently given birth, living in the Hunter New England (HNE) area took part. Eleven women were still smoking; nine had quit. Most were highly aware of the implications of smoking for their babies. Major themes identified for accepting support were: ambivalence towards a need for support, health professional advice, reduction in smoking, and attitudes to Nicotine Replacement Therapy (NRT). Women reported being advised to cut down, rather than to quit; reducing consumption may be a barrier to accepting NRT. Women recommended enhanced clinical support and Aboriginal community engagement in cessation care. DISCUSSION/CONCLUSIONS: Aboriginal women in the HNE area reported quitting or reducing their cigarette intake during pregnancy. Health Professionals working with Aboriginal women during pregnancy should give consistent messages to quit smoking completely, and offer increased, ongoing and extensive smoking cessation support to Aboriginal mothers. Clinical practices could partner with Aboriginal communities to support the delivery of smoking cessation services.

Nurse provision of support to help inpatients quit smoking.

Issue addressed Identification of the factors that facilitate nurses to provide smoking cessation advice to hospitalised patients. Method Six semistructured focus groups with 26 nurses were conducted in June 2015. Participants completed a structured survey to collect patient demographic data and assess attitudes towards their role in addressing smoking cessation among inpatients. Results Important themes that emerged from the qualitative data were: nurses' negative perceptions of smokers, nurses' confidence in their knowledge of smoking cessation care and nurses' uncertainty around whose role it is to provide smoking cessation care. Conclusion Nurses require training in order to confidently and competently address smoking among inpatients as part of routine care. Formal ways to document the smoking status of inpatients and the offer of smoking cessation support from a nurse to an inpatient would enhance the communication between nurses around which inpatients had been asked about their smoking status and which had not. For patients who are resistant to conventional cessation strategies, innovative ways are needed to reduce the harm caused to them by tobacco use. So what? Nurses need to be provided with education and training around smoking cessation to increase their confidence and skills to provide smoking cessation care to inpatients.

Integrating smoking cessation into routine care in hospitals--a randomized controlled trial.

AIMS: To evaluate the effectiveness of a pharmacist-led multi-component smoking cessation programme (GIVE UP FOR GOOD) compared with usual care in hospitalized smokers. DESIGN: Randomized, assessor-blinded, parallel-group trial. SETTING: Three tertiary public hospitals in Australia. PARTICIPANTS: A total of 600 adult in-patient smokers [mean ± standard deviation (SD), age 51 ± 14 years; 64% male] available for 12 months follow-up. INTERVENTIONS: Multi-component hospital pharmacist-led behavioural counselling and/or pharmacotherapy provided during hospital stay, on discharge and 1 month post-discharge, with further support involving community health professionals (n = 300). Usual care comprised routine care provided by hospitals (n = 300). MEASUREMENTS: Two primary end-points were tested using intention-to-treat analysis: carbon monoxide (CO)-validated 1-month sustained abstinence at 6-month follow-up and verified 6-month sustained abstinence at 12-month follow-up. Smoking status and pharmacotherapy usage were assessed at baseline, discharge, 1, 6 and 12 months. FINDINGS: Sustained abstinence rates for intervention and control groups were not significantly different at both 6 months [11.6% (34 of 294) versus 12.6% (37 of 294); odds ratio (OR) = 0.91, 95% confidence interval (CI) = 0.55-1.50] and 12 months [11.6% (34 of 292) versus 11.2% (33 of 294); OR = 1.04, 95% CI = 0.63-1.73]. Secondary end-points, self-reported continuous abstinence at 6 and 12 months, also agreed with the primary end-points. Use of pharmacotherapy was higher in the intervention group, both during hospital stay [52.3% (157 of 300) versus 42.7% (128 of 300); P = 0.016] and after discharge [59.6% (174 of 292) versus 43.5% (128 of 294); P < 0.001]. CONCLUSIONS: A pharmacist-led multi-component smoking cessation intervention provided during hospital stay did not improve sustained abstinence rates at either 6 or 12 months compared with routine hospital care.

An internet based approach to improve general practitioners' knowledge and practices: the development and pilot testing of the "ABC's of vitamin D" program.

BACKGROUND: Online continuing medical education (CME) offers a number of advantages for physicians including flexibility with regards to location and timing of use. In order to effect physician practices and improve patient outcomes, it is important that the development of online CME is theory and evidence-based. OBJECTIVES: This paper aims to describe the development of an online CME program for practising general practitioners (GPs) on vitamin D and sun health called "The ABC's of Vitamin D for GPs" using elements of design principles for physician-education web sites as a framework. The paper will also report the program's usability and acceptability pilot test results. METHODS: The ABC's of Vitamin D program was developed following nine principles: needs assessment; evidence-based content development; multimodal program and modularisation; clinical cases; tailoring and interactivity; audit and feedback; credibility of the web site host; patient education materials; ease of use and navigation. Among the 20 GPs invited, acceptability and useability was tested with 12 GPs (60%) who agreed to participate and were interviewed following use of the program. The study was conducted between 2011 and 2013. RESULTS: An online CME program consisting of eight modules was constructed. Of the 12 participating GPs, most (n=11) reported that the program was clear and easy to understand, logical, easy to navigate, and took a reasonable amount of time (estimated between 1 and 3h) to complete. Eleven of 12 participants said they would use the program as an accredited CME activity and all participants indicated that the program was 'very or somewhat' likely to lead to changes in the advice patients are given. CONCLUSION: This study found that a theory and evidence based approach for the development of an online CME program for GPs was acceptable to users. Further research is needed to examine whether the online CME program is effective at changing GP practices and improving patient outcomes.

Smoky homes: gender, socioeconomic and housing disparities in second hand tobacco smoke (SHS) exposure in a large population-based Australian cohort.

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

Novel setting for addressing tobacco-related disparities: a survey of community welfare organization smoking policies, practices and attitudes.

Research in the United States and Australia acknowledges the potential of non-government social and community service organizations (SCSOs) for reaching socially disadvantaged smokers. This study aimed to describe SCSO smoking policies and practices, and attitudes of senior staff towards smoking and cessation. It also investigated factors associated with positive tobacco control attitudes. In 2009, a cross-sectional telephone survey was undertaken of senior staff in Australian SCSOs, 149 respondents representing 93 organizations completed the survey (response rate=65%; 93/142). Most service clients (60%) remained in programs for 6 months plus, and 77% attended at least weekly. Although 93% of respondents indicated they had an organizational smoking policy, it often did not include the provision of smoking cessation support. Most respondents indicated that client smoking status was not recorded on case notes (78%). Attitudes were mostly positive towards tobacco control in SCSOs, with a mean (standard deviation) score of 8.3 (2.9) of a possible 13. The practice of assessing clients' interest in quitting was the only statistically significant factor associated with high tobacco control attitude scores. The results suggest that SCSOs are appropriate settings for reaching socially disadvantaged smokers with cessation support. Although generally receptive to tobacco control, organizations require further support to integrate smoking cessation support into usual care. In particular, education, training and support for staff to enable them to help their clients quit smoking is important.

Money as motivation to quit: a survey of a non-random Australian sample of socially disadvantaged smokers' views of the acceptability of cash incentives.

OBJECTIVE: This study aimed to a) assess acceptability of personal financial incentives to socially disadvantaged smokers and non-smokers; b) examine factors associated with acceptability; and c) examine preferred levels of incentive amounts. METHODS: A cross-sectional touch screen computer survey was conducted between February and October 2010 in New South Wales, Australia. Participants were clients experiencing financial or social hardship and receiving emergency welfare aid from a non-government social and community service organisation. RESULTS: Of 383 participants (69% response rate), 46% believed personal financial incentives were an excellent/good idea, 47% believed personal financial incentives did more good than harm and 61% agreed they would motivate smokers to quit. High acceptability ratings were associated with participants being female, current smokers, living in low socioeconomic areas, experiencing smoking-induced deprivation, making a previous quit attempt and intending to quit in the next 6 months. When asked what amount of incentive they felt would be acceptable, 23% selected amounts between $50 and $500 AUD and 37% selected amounts over $500 AUD. CONCLUSIONS: Given high smoking prevalence among socially disadvantaged groups and consequent health disparities, it is imperative novel methods of encouraging smoking cessation are explored and tested. This survey found financial incentives may be an acceptable method. Further research to understand all possible positive and negative effects is warranted.

The validity and reliability of an interactive computer tobacco and alcohol use survey in general practice.

BACKGROUND: Uncertainty regarding the accuracy of the computer as a data collection or patient screening tool persists. Previous research evaluating the validity of computer health surveys have tended to compare those responses to that of paper survey or clinical interview (as the gold standard). This approach is limited as it assumes that the paper version of the self-report survey is valid and an appropriate gold standard. OBJECTIVES: First, to compare the accuracy of computer and paper methods of assessing self-reported smoking and alcohol use in general practice with biochemical measures as gold standard. Second, to compare the test re-test reliability of computer administration, paper administration and mixed methods of assessing self-reported smoking status and alcohol use in general practice. METHODS: A randomised cross-over design was used. Consenting patients were randomly assigned to one of four groups; Group 1. C-C : completing a computer survey at the time of that consultation (Time 1) and a computer survey 4-7 days later (Time 2); Group 2. C-P: completing a computer survey at Time 1 and a paper survey at Time 2; Group 3. P-C: completing a paper survey at Time 1 and a computer survey at Time 2; and Group 4. P-P: completing a paper survey at Time 1 and 2. At Time 1 all participants also completed biochemical measures to validate self-reported smoking status (expired air carbon monoxide breath test) and alcohol consumption (ethyl alcohol urine assay). RESULTS: Of the 618 who were eligible, 575 (93%) consented to completing the Time 1 surveys. Of these, 71% (N=411) completed Time 2 surveys. Compared to CO, the computer smoking self-report survey demonstrated 91% sensitivity, 94% specificity, 75% positive predictive value (PPV) and 98% negative predictive value (NPV). The equivalent paper survey demonstrated 86% sensitivity, 95% specificity, 80% PPV, and 96% NPV. Compared to urine assay, the computer alcohol use self-report survey demonstrated 92% sensitivity, 50% specificity, 10% PPV and 99% NPV. The equivalent paper survey demonstrated 75% sensitivity, 57% specificity, 6% PPV, and 98% NPV. Level of agreement of smoking self-reports at Time 1 and Time 2 revealed kappa coefficients ranging from 0.95 to 0.98 in each group and hazardous alcohol use self-reports at Time 1 and Time 2 revealed kappa coefficients ranging from 0.90 to 0.96 in each group. CONCLUSION: The collection of self-reported health risk information is equally accurate and reliable using computer interface in the general practice setting as traditional paper survey. Computer survey appears highly reliable and accurate for the measurement of smoking status. Further research is needed to confirm the adequacy of the quantity/frequency measure in detecting those who drink alcohol. Interactive computer administered health surveys offer a number of advantages to researchers and clinicians and further research is warranted.

Evaluation of an instrument to assess the needs of patients with cancer. Supportive Care Review Group.

BACKGROUND: This study aimed to assess the face, content, and construct validity and the internal reliability of a tool for assessing the generic needs of patients with cancer (the Supportive Care Needs Survey). METHODS: A total of 1,492 consecutive patients attending the surgical, radiation, or medical oncology departments of 9 cancer treatment centers in New South Wales, Australia, were asked to participate. Of the 1,370 eligible patients, 1,354 (99%) consented to participate and 888 (65%) completed the survey. Eligible consenting patients were given a Supportive Care Needs Survey to complete at home and return by mail within 7 days. RESULTS: In the assessment of construct validity, the principal components method of factor analysis identified 5 factors with eigenvalues greater than 1, which together accounted for 64% of the total variance (patients' needs in the domains of psychologic, health system and information, physical and daily living, patient care and support, and sexuality). Face and content validity were found to be high following pilot tests and tests of reading ease. Internal reliability coefficients (Cronbach alpha) of all 5 factor-based scales were found to be substantial, ranging from 0.87 to 0.97. CONCLUSIONS: These findings suggest that the Supportive Care Needs Survey provides a reliable and valid index of the global needs of oncology patients. The standardized and widespread application of this instrument is recommended following further refinement and evaluation.

The unmet supportive care needs of patients with cancer. Supportive Care Review Group.

BACKGROUND: The aim of this study was to determine the prevalence and predictors of the perceived unmet needs of cancer patients undergoing treatment for their disease at public treatment centers. METHODS: A total of 1,492 consecutive patients attending the surgical, radiation, or medical oncology departments of 9 major public cancer treatment centers in New South Wales, Australia, were asked to participate. Of the 1,370 eligible patients, 1,354 (99%) consented to participate and 888 (65%) returned completed surveys. Eligible consenting patients were given a Supportive Care Needs Survey to complete at home and return by mail within 7 days. RESULTS: Patients' perceived needs were assessed across the following five areas: psychologic, health system and information, physical and daily living, patient care and support, and sexuality. Patients' perceived needs were highest in the psychologic, health system and information, and physical and daily living domains. Logistic regression modeling revealed subgroups of patients with different types of needs. The significant predictors of reporting some unmet need for help varied according to the domain examined. CONCLUSIONS: This statewide study shows that cancer patients experience high levels of unmet needs across the range of domains examined. The study provides information that may be valuable in identifying areas where interventions could be tested and evaluated in an attempt to address the unmet needs of people living with cancer.

Randomized controlled trial of a computer strategy to increase general practitioner preventive care.

BACKGROUND: Previous interventions targeting primary care practitioners with the aim of increasing preventive care delivery have demonstrated limited effectiveness. The primary aim of this study was to assess the effectiveness of a computerized continuing medical education program to increase rates of three screening behaviors (cholesterol, blood pressure, and cervical screening) and to identify three risk behaviors (smoking, alcohol consumption, benzodiazepine use) in general practice. METHODS: Nineteen general practitioners were randomly allocated to intervention or control conditions. Those given the intervention received a computerized feedback system. The intervention was delivered using a touch-screen computer located in the surgery waiting area. The preventive behaviors of interest were patient smoking, alcohol use, benzodiazepine use, and blood pressure, cholesterol and cervical screening using the Papanicolou test. Differences in performance by group in each of the outcomes was measured at baseline and 3-month follow-up. Logistic regression analyses with generalized estimating equations were conducted as the main analyses. RESULT: At 3-month follow-up, statistically significant differences were evident in the following outcome measures: accurate classification of benzodiazepine users (z = 2.8540, P < 0.05); accurate classification of non-benzodiazepine users (z = 2.7339, P < 0.05); accurate classification of hazardous or harmful alcohol drinkers (z = 2.3079, P < 0.02); blood pressure screening (z = 3.4136, P < 0.001); and cholesterol screening (z = 6.6313, P < 0.001). CONCLUSION: A computerized system of performance-specific feedback was effective at increasing some preventive care services in general practice.

Self-reported cervical screening practices and beliefs of women from urban, rural and remote regions.

This survey aimed to explore women's perceptions of a number of issues relating to the availability and utilisation of cervical cancer screening services in the rural, remote and urban regions of New South Wales (NSW) Australia. The survey involved urban, rural and remote regions of NSW determined by the definition of the Department of Community Services and Health. This was a cross-sectional telephone survey. Of the 339 eligible urban households, 265 (78%) completed interviews; of the 286 eligible rural households, 238 (83%) completed interviews; of the 285 eligible remote households, 230 (81%) completed interviews. Telephone contact was made with randomly selected households in each region. Women in the households were asked to complete a computer-assisted telephone interview. The survey addressed a number of issues relating to cervical screening: cervical cancer risk status; provider of Pap smear service; distance travelled to have a Pap smear; perceived barriers and facilitators to cervical screening. There was no statistically significant difference in the proportions of women from urban (74%), rural (76%), and remote (71%) regions who reported having a Pap smear in the 2 years preceding the survey. General practitioners provided the majority (more than 70%) of tests irrespective of region. Compared with women from urban areas, women from rural and remote areas were almost twice as likely to have had their last Pap smear from a male general practitioner. A greater proportion of women from remote regions had to travel for 60 minutes or more to access providers of Pap smear services. Few differences in the top three reported barriers to, and facilitators for screening were evident between regions and between those women who had and had not been adequately screened. Issues of distance, isolation and access to alternative service providers are a concern to women in rural and remote regions and should be considered by those involved in the implementation of cervical cancer screening services.

Surgeons' opinions about the NHMRC clinical practice guidelines for the management of early breast cancer.

OBJECTIVE: To explore the opinions of surgeons about the NHMRC clinical practice guidelines for the management of early breast cancer (the Guidelines) and their views about and use of the accompanying Consumer's guide. DESIGN: Cross-sectional telephone survey. PARTICIPANTS AND SETTING: Surgeons throughout Australia who manage breast cancer, designated as "breast" or "general" (members or non-members of the Royal Australasian College of Surgeons' Section of Breast Surgery) and "urban" or "rural". RESULTS: Among 150 respondents (64% response rate) more than 80% of surgeons reported having read all or most of the Guidelines and believed they were useful in improving women's management and wellbeing, easy to understand, evidence-based, a good summary of recent evidence, and that they would assist agreement between women and healthcare providers. Surgeons agreed with most of the recommendations in the Guidelines, but 26% disagreed that "women should ideally be treated by a specialist who treats a large number of similar patients and who has access to the full range of treatment options in a multidisciplinary setting". In terms of medicolegal implications, 41% believed that the Guidelines would protect clinicians, while, of the 37% of surgeons who believed that they would expose doctors to increased problems, significantly more breast than general surgeons believed this (50% v. 19%; P < 0.001). Only 37% of surgeons routinely gave the Consumer's guide to all or more than half their patients. CONCLUSIONS: Surgeons are generally positive about the Guidelines, but certain issues should be addressed if they are to be optimally implemented, including confusion about the medicolegal implications, perceived difficulties with providing multidisciplinary care and poor use of the Consumer's guide.

Women's experiences of having a colposcopic examination: self-reported satisfaction with care, perceived needs and consequences.

This study was conducted in seven gynaecological clinics in New South Wales (NSW), Australia. The study aimed to assess the level of satisfaction with care, unmet needs and consequences following the procedure reported by women having a colposcopic examination. Of the 161 eligible women attending colposcopy clinics who were approached to take part, 156 (97%) gave written consent to participate and 138 (86%) completed interviews. Consenting women were telephoned within 1 week of their clinic visit to complete a computer-assisted telephone interview (CATI). The survey addressed a number of issues relating to the care they received during their colposcopic examination: satisfaction with care, satisfaction with the waiting time to have a colposcopy, preferences for provider gender, information and health care needs while waiting for the colposcopy, information and health care needs during the colposcopy, short-term physical consequences and shortterm psychosocial consequences of the procedure. Results indicate that satisfaction with care among women ranged from 69% to 96%. The highest expressed needs while waiting for the colposcopy were for information about risks of cancer (91%), reasons for needing a colposcopy (86%), and the colposcopy procedure (86%). Women reported that outcomes such as anxiety and disinterest in sex had further worsened or not been improved following the colposcopy. The results indicate that interventions to address specific concerns would need to be designed, implemented and evaluated.