Understanding ethnic inequities associated with tobacco use in Aotearoa New Zealand: a quantitative analysis.

Despite the inclusion of both individual interventions and population-based measures in the Aotearoa New Zealand (Aotearoa NZ) Tobacco Control Programme, the gap between Maori, Pacific peoples and European/Asian/Other (EAO) populations in tobacco use has not decreased significantly. Tobacco control interventions that focus on individual behaviour change have produced little impact towards reducing tobacco smoking inequities for Maori and Pacific peoples in Aotearoa NZ. Using data from the New Zealand Health Survey (NZHS), this research investigates the impact of the wider determinants of health and individual-level factors on inequities in tobacco use between Maori, Pacific peoples and EAO. A conceptual framework was developed to support the theoretical positioning of this research and to inform data categorization, framing, discourse, analyses and interpretation. We conducted hierarchical regression to examine the effect of factors from each domain on ethnic inequities in tobacco use. We found that socioeconomic factors accounted for a significant amount of the disparity in adults currently smoking between Maori and Pacific peoples and EAO. Our results suggest that socioeconomic factors may be a more effective target of intervention than individual behaviours for reducing tobacco-related inequities. Addressing the broader determinants of health through comprehensive cross-agency cooperation to reduce ethnic inequities in tobacco use in Aotearoa NZ is likely to be more effective than individual behaviour change approaches.

Unsupervised home spirometry is not equivalent to supervised clinic spirometry in children and young people with cystic fibrosis: Results from the CLIMB-CF study.

BACKGROUND: Handheld spirometry allows monitoring of lung function at home, of particular importance during the COVID-19 pandemic. Pediatric studies are unclear on whether values are interchangeable with traditional, clinic-based spirometry. We aimed to assess differences between contemporaneous, home (unsupervised) and clinic (supervised) spirometry and the variability of the former. The accuracy of the commercially available spirometer used in the study was also tested. METHODS: Data from participants in the Clinical Monitoring and Biomarkers to stratify severity and predict outcomes in children with cystic fibrosisc (CLIMB-CF) Study aged ≥ 6 years who had paired (±1 day) clinic and home forced expiratory volume in 1 s (FEV1 ) readings were analyzed. Variability during clinical stability over 6-months was assessed. Four devices from Vitalograph were tested using 1 and 3 L calibration syringes. RESULTS: Sixty-seven participants (median [interquartile range] age 10.7 [7.6-13.9] years) provided home and clinic FEV1 data pairs. The mean (SD) FEV1 % bias was 6.5% [±8.2%]) with wide limits of agreement (-9.6% to +22.7%); 76.2% of participants recorded lower results at home. Coefficient of variation of home FEV1 % during stable periods was 9.9%. Data from the testing of the handheld device used in CLIMB-CF showed a potential underread. CONCLUSION: In children and adolescents, home spirometry using hand-held equipment cannot be used interchangeably with clinic spirometry. Home spirometry is moderately variable during clinical stability. New handheld devices underread, particularly at lower volumes of potential clinical significance for smaller patients; this suggests that supervision does not account fully for the discrepancy. Opportunities should be taken to obtain dual device measurements in clinic, so that trend data from home can be utilized more accurately.

Understanding patient barriers and facilitators to uptake of lung screening using low dose computed tomography: a mixed methods scoping review of the current literature.

BACKGROUND: Targeted lung cancer screening is effective in reducing mortality by upwards of twenty percent. However, screening is not universally available and uptake is variable and socially patterned. Understanding screening behaviour is integral to designing a service that serves its population and promotes equitable uptake. We sought to review the literature to identify barriers and facilitators to screening to inform the development of a pilot lung screening study in Scotland. METHODS: We used Arksey and O'Malley's scoping review methodology and PRISMA-ScR framework to identify relevant literature to meet the study aims. Qualitative, quantitative and mixed methods primary studies published between January 2000 and May 2021 were identified and reviewed by two reviewers for inclusion, using a list of search terms developed by the study team and adapted for chosen databases. RESULTS: Twenty-one articles met the final inclusion criteria. Articles were published between 2003 and 2021 and came from high income countries. Following data extraction and synthesis, findings were organised into four categories: Awareness of lung screening, Enthusiasm for lung screening, Barriers to lung screening, and Facilitators or ways of promoting uptake of lung screening. Awareness of lung screening was low while enthusiasm was high. Barriers to screening included fear of a cancer diagnosis, low perceived risk of lung cancer as well as practical barriers of cost, travel and time off work. Being health conscious, provider endorsement and seeking reassurance were all identified as facilitators of screening participation. CONCLUSIONS: Understanding patient reported barriers and facilitators to lung screening can help inform the implementation of future lung screening pilots and national lung screening programmes.

Optimizing the implementation of lung cancer screening in Scotland: Focus group participant perspectives in the LUNGSCOT study.

INTRODUCTION: Targeted lung cancer screening is effective in reducing lung cancer and all-cause mortality according to major trials in the United Kingdom and Europe. However, the best ways of implementing screening in local communities requires an understanding of the population the programme will serve. We undertook a study to explore the views of those potentially eligible for, and to identify potential barriers and facilitators to taking part in, lung screening, to inform the development of a feasibility study. METHODS: Men and women aged 45-70, living in urban and rural Scotland, and either self-reported people who smoke or who recently quit, were invited to take part in the study via research agency Taylor McKenzie. Eleven men and 14 women took part in three virtual focus groups exploring their views on lung screening. Focus group transcripts were transcribed and analysed using thematic analysis, assisted by QSR NVivo. FINDINGS: Three overarching themes were identified: (1) Knowledge, awareness and acceptability of lung screening, (2) Barriers and facilitators to screening and (3) Promoting screening and implementation ideas. Participants were largely supportive of lung screening in principle and described the importance of the early detection of cancer. Emotional and psychological concerns as well as system-level and practical issues were discussed as posing barriers and facilitators to lung screening. CONCLUSIONS: Understanding the views of people potentially eligible for a lung health check can usefully inform the development of a further study to test the feasibility and acceptability of lung screening in Scotland. PATIENT OR PUBLIC CONTRIBUTION: The LUNGSCOT study has convened a patient advisory group to advise on all aspects of study development and implementation. Patient representatives commented on the focus group study design, study materials and ethics application, and two representatives read the focus group transcripts.

Increasing uptake to a lung cancer screening programme: building with communities through co-design.

BACKGROUND: Lung cancer is the most common cause of cancer death in the UK. Low-dose computed tomography (LDCT) screening has been shown to identify lung cancer at an earlier stage. A risk stratified approach to LDCT referral is recommended. Those at higher risk of developing lung cancer (aged 55 + , smoker, deprived area) are least likely to participate in such a programme and, therefore, it is necessary to understand the barriers they face and to develop pathways for implementation in order to increase uptake. METHODS: A 2-phased co-design process was employed to identify ways to further increase opportunity for uptake of a lung cancer screening programme, using a risk indicator for LDCT referral, amongst people who could benefit most. Participants were members of the public at high risk from developing lung cancer and professionals who may provide or signpost to a future lung cancer screening programme. Phase 1: interviews and focus groups, considering barriers, facilitators and pathways for provision. Phase 2: interactive offline booklet and online surveys with professionals. Qualitative data was analysed thematically, while descriptive statistics were conducted for quantitative data. RESULTS: In total, ten barriers and eight facilitators to uptake of a lung cancer screening programme using a biomarker blood test for LDCT referral were identified. An additional four barriers and four facilitators to provision of such a programme were identified. These covered wider themes of acceptability, awareness, reminders and endorsement, convenience and accessibility. Various pathway options were evidenced, with choice being a key facilitator for uptake. There was a preference (19/23) for the provision of home test kits but 7 of the 19 would like an option for assistance, e.g. nurse, pharmacist or friend. TV was the preferred means of communicating about the programme and fear was the most dominant barrier perceived by members of the public. CONCLUSION: Co-design has provided a fuller understanding of the barriers, facilitators and pathways for the provision of a future lung cancer screening programme, with a focus on the potential of biomarker blood tests for the identification of at-risk individuals. It has also identified possible solutions and future developments to enhance uptake, e.g. Embedding the service in communities, Effective communication, Overcoming barriers with options. Continuing the process to develop these solutions in a collaborative way helps to encourage the personalised approach to delivery that is likely to improve uptake amongst groups that could benefit most.

Strengthening primary health care: contributions of young professional-led communities of practice.

BACKGROUND: Health systems that have strong primary health care at their core have overall better patient outcomes. Primary health care is key to achieving Universal Health Coverage and the broader health-related Sustainable Development Goals by 2030. In 2018, at the launch of the Declaration of Astana, the World Health Organization formed the inaugural Primary Health Care Young Leaders' Network. OBJECTIVE: This paper aims to demonstrate the scope for young professional-led communities of practice in fostering support systems for young leaders and strengthening the delivery of primary health care at multiple levels. METHODS: A description of the Young Leaders' Network community of practice model is presented, with examples of the work the members are doing, individually and collectively, to advance the science and practice of primary health care. RESULTS: This initiative brought together 21 individuals from across the world, working across disciplines and within an array of socioeconomic contexts to improve primary health care in their respective countries. CONCLUSIONS: This youth-led community of practice is able to share knowledge, evidence and resources to inform clinical and public health activities, policy initiatives, advocacy and research to improve primary health care delivery and health outcomes for communities across the globe.

Information-seeking behaviours and uncertainty around accessing primary care in the changing landscape of the COVID-19 pandemic: a qualitative study.

BACKGROUND: The COVID-19 pandemic has had and will continue to have a disproportionate effect on the most vulnerable. Public health messaging has been vital to mitigate the impact of the pandemic, but messages intended to slow the transmission of the virus may also cause harm. Understanding the areas where public health messaging could be improved may help reduce this harm. AIM: To explore and understand health communication issues faced by those most likely to be impacted by the COVID-19 pandemic. DESIGN & SETTING: A qualitative study using online surveys. The area of focus was Fife, a local authority in Scotland, UK. METHOD: Two consecutive surveys were conducted. Survey 1 explored the observations of support workers and Facebook group moderators, and focused on key issues faced by service users, as well as examples of good practice (n = 19). Survey 2 was aimed at community members, and focused on issues regarding access to and communication around access to primary care (n = 34). RESULTS: Survey 1 found broad issues around communication and access to primary care services. Survey 2 emphasised key issues in accessing primary care, including: (a) the lengthy process of making appointments; (b) feeling like a burden for wanting to be seen; (c) a lack of confidence in remote triaging and consultations; and (d) not knowing what to expect before getting an appointment. CONCLUSION: Clear issues regarding access to primary care were identified. The new understanding of these issues will inform a co-creation process designed to develop clear, actionable, and effective public health messages centred on improving access to primary care.

Empowering children and young people who have asthma.

Asthma is the most common chronic condition of childhood. In this review, we discuss an overview of strategies to empower children and young people with asthma. The key aspects of empowerment are to enable shared decision making and self-management, and help children minimise the impact of asthma on their life. The evidence behind these strategies is either sparse or heterogenous, and it is difficult to identify which interventions are most likely to improve clinical outcomes. Wider determinants of health, in high-resource and low-resource settings, can be disempowering for children with asthma. New approaches to technology could help empower young people with asthma and other chronic health conditions.

Patients' views on involving general practice in bowel cancer screening: a South Australian focus group study.

OBJECTIVES: To explore patients' experiences of bowel cancer screening and its promotion, and perspectives on possible input from general practice for improving screening rates. DESIGN: Qualitative focus group study underpinned by a phenomenological approach. SETTING: Three general practice clinics in metropolitan South Australia. PARTICIPANTS: Thirty active general practice patients, aged 50-74 years (60% female) who were eligible for the National Bowel Cancer Screening Program. FINDINGS: Factors affecting screening were described, with particular concerns regarding the nature of the test, screening process and culture. There were mixed views on the role for general practice in bowel cancer screening; some participants appreciated the current process and viewed screening as out of scope of primary care services, while others were in support of general practice involvement. Roles for general practice were proposed that comprised actions across the continuum from providing information through to reminders and the provision and collection of screening kits. With a view that multifaceted strategies are required to encourage participation, community-based solutions were suggested that centred on improving screening culture and education. CONCLUSIONS: There was a view among participants that general practice could play a useful role in supporting the uptake of the National Bowel Cancer Screening Program, however participants saw a need for multiple strategies at different levels and under different jurisdictions.

E-health: psychosocial challenges for South Australian rural mental health consumers.

INTRODUCTION: Rates of mental health issues are increasing, coupled with insufficient resources to provide appropriate support. This is a particular challenge for rural areas in Australia that face significant social inequities including a scarcity of health resources. E-health initiatives are often proposed to maximise the number of rural mental health consumers able to receive support. The Australian Government has prioritised e-health within the remit of the Australian Digital Health Agency and the National Digital Health Strategy. However, despite increasing interest in e-health in policy and practice settings, uptake has been underwhelming. This study investigated the factors affecting the likely engagement with the internet, both for general and e-health purposes, within the context of South Australian rural mental health consumers. The focus was on psychosocial predictors, which embraced intrinsic (motivation), as well as extrinsic factors concerning equity, such as income, occupation, education and geographic location. METHODS: Participants in this quantitative study included 208 mental health consumers in rural South Australia who had recently accessed a local health network mental health service. Data were sourced from the service's clinical management database and a questionnaire constructed for the study. The questionnaire included measures of personal characteristics, motives, equity and internet use. RESULTS: Motives and equity-related variables were directly linked to general internet use, which subsequently affected the likelihood of using the internet for health purposes. Intrinsic rather than extrinsic factors were the most significant drivers of internet use; that is, higher levels of general internet use were associated with being younger, having stronger motivation, greater trust, higher education, being employed, having a higher income and having home internet access. For health internet use, the identified significant associations were more modest and included only being younger, having stronger motivation, and greater trust. The model indicated that there were no direct predictors of internet use for health beyond use of the internet for general purposes. However, key study variables provided significant indirect paths to health internet use. General internet use was strongly influenced by motivation, and age and equity to a lesser extent. Motivation was influenced by trust, and age and equity, with trust also influenced by age and equity. CONCLUSION: This quantitative investigation sought to describe the barriers to and enablers of internet use generally, based on the assumption that before people will use the internet for health, they need to be prepared to use it for general purposes. The model proposed in the current research offers an indication of some of the factors that may influence rural mental health consumers' use of the internet for both general and health purposes. To appropriately design future e-health initiatives, the initial focus must be on consumers' individual capacity and willingness to use the internet generally. Policymakers and service providers are acutely interested in leveraging internet use to facilitate positive health outcomes. Understanding the factors that affect rural mental health consumers' use of the internet in general is beneficial in informing the efficient allocation of resources and the appropriate design of e-health initiatives to produce innovative solutions.

Patient perspectives on colorectal cancer screening and the role of general practice.

BACKGROUND: Colorectal cancer (CRC) is the second most frequent cause of cancer death in Australia. Early detection can reduce incidence and mortality. General practice-based initiatives have been proposed to improve CRC screening rates but to date have had modest impact. As there is limited research into the patient experience of CRC screening decision making, this study explored patient perspectives on CRC screening and the potential role for general practice. METHODS: Ten participants, aged between 50 and 74, from a general practice in South Australia were recruited by practice staff. Semi-structured interviews were conducted. Concurrent data collection and analysis were performed, guided by interpretative phenomenological analysis. RESULTS: Two key themes were evident: attitudes toward screening and potential roles for general practice. Participants structured the experience of screening in terms of being proactive, ambivalent or avoidant. Roles for general practice centred on tasks as educators, trusted advisors, monitors and screeners. Mixed views on whether general practice involvement was necessary prompted consideration of additional sources of health information and motivation around screening. CONCLUSIONS: Exploration of the patient experience provides insight into how participants make sense of screening and perceived roles for general practice (or other agents) in screening. There is satisfaction with current Government-driven processes but perceived value in general practice playing a complementary part in increasing screening rates. A multifaceted strategy, accounting for attitudes, is required to improve screening and population health outcomes.

Surviving or thriving in the primary health care research workforce: the Australian experience.

Primary healthcare research strives for high-quality, priority-driven research to inform policy and practice. This relies on a robust and sustainable workforce to tackle complex problems faced in primary health care locally and globally. The current study investigated characteristics, experiences and career paths of the Australian primary healthcare research workforce. Thirty-seven former Research Higher Degree students from University Departments of General Practice and Rural Health completed a survey. Number of provisions for researchers and career path clarity were associated with job satisfaction. Motivators to stay in research included job satisfaction, research in role descriptions, and identification of problems requiring change. Barriers related to funding, time, and other work roles taking priority were identified. Comparisons were made between participants self-identifying as working in primary healthcare research ('stayers'; n=22) and those no longer part of this workforce ('leavers'; n=15). Leavers were more likely to be in permanent full-time work whereas stayers had experienced more career progression and mentoring. This study raises challenges faced by primary healthcare researchers and will inform strategies for supporting the sustainability of this workforce.

Should the healthcare compass in Australia point towards value-based primary healthcare?

This paper provides an overview of quality improvement in healthcare in an Australian context. Specifically, the paper considers issues around defining, quantifying, recording and incentivising quality improvement and accountability in primary healthcare. The role of newly emerging Primary Health Networks provides a context for the discussion. The paper draws on international learnings that provide a framework for examining the important elements of quality improvement among reforming primary healthcare organisations in order to support healthcare providers and offer an evidence base for policy makers and peak bodies moving forward.

The contribution of a knowledge exchange organisation in primary healthcare.

BACKGROUND: The use of relevant quality research and evidence to inform policy and practice is complex, takes time and requires skill. Over the past 20 years, a knowledge exchange organisation (the Primary Health Care Research and Information Service [PHCRIS]) has developed, implemented and evaluated ways to accelerate the use of research and evidence to strengthen Australian primary healthcare and thereby enhance health. OBJECTIVE: This paper outlines how PHCRIS operates to accelerate the use of research and evidence in primary healthcare policy and practice. DISCUSSION: PHCRIS takes an integrated approach to accelerate the use of research and evidence in primary healthcare by sharing information, research and evidence; summarising and synthesising research; building capacity; and facilitating knowledge exchange. Resources developed to support this approach have a strong emphasis on access, quality, relevance and timeliness. The success of the approach has been achieved through respectful and effective engagement with stakeholders, extensive use of technologies and continuous quality improvement.

Six elements of integrated primary healthcare.

BACKGROUND: Integrated care has the potential to deliver efficiencies and improvements in patient experiences and health outcomes. Efforts towards integrated care, especially at the primary and community health levels, have increasingly been under focus, both nationally and internationally. In Australia, regional integration is a priority, and integration of care is a task for meso-level organisations such as Primary Health Networks (PHNs). OBJECTIVE: This paper seeks to provide a list of elements and questions for consideration by organisations working across primary healthcare settings, looking to enact and improve the delivery of integrated care. DISCUSSION: Six elements that consistently emerged during the development of a series of rapid reviews on integrated primary healthcare in Australia are presented in this paper. The elements identified are context, governance and leadership, infrastructure, financing, engagement, and communication. They offer a starting point for reflection in the planning and practices of organisations in their drive for continuous improvements in integrated care.

Comparisons of the utility of researcher-defined and participant-defined successful ageing.

AIM: To investigate the impact of different approaches for measuring 'successful ageing', four alternative researcher and participant definitions were compared, including a novel measure informed by cluster analysis. Rates of successful ageing were explored, as were their relative associations with age and measures of successful adaptation, to assess construct validity. METHOD: Participants, aged over 65, were recruited from community-based organisations. Questionnaires (assessing successful ageing, lifestyle activities and selective optimisation with compensation) were completed by 317 individuals. RESULTS: Successful ageing ranged from 11.4% to 87.4%, with higher rates evident from participant definitions. Though dependent upon the definition, successful agers were typically younger, reported greater engagement with lifestyle activities and more frequent optimisation. CONCLUSIONS: While the current study suggested an improved classification algorithm using a common research definition, future research should explore how subjective and objective aspects of successful ageing may be combined to derive a measure relevant to policy and practice.

Transition from the spouse dementia caregiver role: A change for the better?

One in 15 Australians over 65 experience dementia, and are commonly supported by spouses. Evidence demonstrates declining wellbeing for these caregivers as their role continues. There are indications of improvement once caregivers transition out of the role (recovery) but alternate suggestions that caregiving stress may be too damaging to be appeased (wear and tear). It seems plausible that reason for transition (care recipient's move into residential care or death) will affect caregivers' outcomes. A synthetic cohort method compared caregivers' stress and wellbeing prior to, and one and two years post-transition. There was evidence of wear and tear for physical wellbeing but recovery for psychological wellbeing over time; with little difference based on reason for transition. Caregiver outcomes seem to be a function of the action rather than the reason for transition, but factors such as age must be considered when designing methods to support post-transition wellbeing.

Facilitating access to evidence: Primary Health Care Search Filter.

BACKGROUND: The evidence base developed by, and relevant to, primary health care (PHC) is rapidly increasing. With the wealth of literature available, searchers trying to find PHC-specific citations can feel overwhelmed. OBJECTIVES: Flinders Filters and the Primary Health Care Research & Information Service collaborated to develop a search filter enabling efficient and effective retrieval of relevant PHC literature. METHODS: Stage 1 involved developing a PHC Search Filter in the OvidSP Medline platform using a rigorous experimental methodology. The search filter was then translated for Web-based 'one-click searching' in PubMed during Stage 2. Stage 3 involved planning and implementing a mixed-methods evaluation. RESULTS: The search filter sensitivity was 77.0% with a post hoc relevance assessment of 78.3%. Four months after its launch, a mixed-methods study evaluated the PHC Search Filter. With 90 respondents, analysis of data from the online survey demonstrated overarching benefits, a positive response to the tool and directions for further refinement of the PHC Search Filter. DISCUSSION: Designing the PHC Search Filter followed an established method that ensures the tool offers a validated search strategy. Evaluation results suggest that the PHC Search Filter is a useful tool that is easy to navigate. Challenges for the Filter relate to access to full text articles, while challenges for the evaluation relate to the small sample size. CONCLUSIONS: The PHC Search Filter reduces the burden associated with literature searching, increases the value of the results that are received and provides a useful resource to improve the likelihood of incorporating relevant evidence into policy and practice.

The contribution of Primary Health Care Research, Evaluation and Development-supported research to primary health care policy and practice.

The importance of primary health care (PHC) research is well understood yet conducting this research can be challenging. Barriers include a lack of funding, support and opportunity. In 2000 the Australian government introduced the Primary Health Care Research, Evaluation and Development (PHCRED) Strategy to address the gap in high-quality research. One component of the strategy, the Research Capacity Building Initiative, provided funding to university departments of general practice and rural health, allowing them to expand their pool of researchers and produce more research relevant to policy and practice. This study investigates the impact of phase two of the PHCRED Strategy by analysing peer-reviewed publications from PHCRED-supported departments. Research output was recorded from 2006 to 2010 incorporating 661 publications in 212 journals. Rural departments often had fewer resources than urban departments yet demonstrated steady research contributions focusing on issues relevant to their community. Since its inception the PHCRED Strategy has enabled development of research capacity and contributed to the body of PHC knowledge. While PHC is a diverse field, reflected in the publications produced, the themes underlying much of this work were representative of current health reform and the priority areas and building blocks of the National PHC Strategy.