Ethics and the co-production of knowledge.

There is an increasing focus on co-production in public health research. By their very nature, such research endeavours involve a different set of relationships, goals, and values than traditional research. To date, ethical issues that arise during the co-production process are dealt with on an ad hoc and case-by-case basis. There is a need to make the ethical considerations of co-production explicit. This article outlines several ethical values that could be considered in co-production using two different ethical frameworks. It also draws upon practical co-production research that highlights some of the ethical issues that arise. It argues that all stakeholders in the co-production process have a responsibility to ensure that the knowledge they co-produce is as beneficial as possible. In doing so, they must adhere to a set of ethics surrounding the generation of such knowledge, including health equity, intellectual property considerations, and respect for the rights of individuals and groups.

Evaluation of the Victorian Healthy Homes Program: protocol for a randomised controlled trial.

INTRODUCTION: The evaluation of the Victorian Healthy Homes Program (VHHP) will generate evidence about the efficacy and cost-effectiveness of home upgrades to improve thermal comfort, reduce energy use and produce health and economic benefits to vulnerable households in Victoria, Australia. METHODS AND ANALYSIS: The VHHP evaluation will use a staggered, parallel group clustered randomised controlled trial to test the home energy intervention in 1000 households. All households will receive the intervention either before (intervention group) or after (control group) winter (defined as 22 June to 21 September). The trial spans three winters with differing numbers of households in each cohort. The primary outcome is the mean difference in indoor average daily temperature between intervention and control households during the winter period. Secondary outcomes include household energy consumption and residential energy efficiency, self-reported respiratory symptoms, health-related quality of life, healthcare utilisation, absences from school/work and self-reported conditions within the home. Linear and logistic regression will be used to analyse the primary and secondary outcomes, controlling for clustering of households by area and the possible confounders of year and timing of intervention, to compare the treatment and control groups over the winter period. Economic evaluation will include a cost-effectiveness and cost-benefit analysis. ETHICS AND DISSEMINATION: Ethical approval was received from Victorian Department of Human Services Human Research Ethics Committee (reference number: 04/17), University of Technology Sydney Human Research Ethics Committee (reference number: ETH18-2273) and Australian Government Department of Veterans Affairs. Study results will be disseminated in a final report and peer-reviewed journals. TRIAL REGISTRATION NUMBER: ACTRN12618000160235.

Criteria for developing, assessing and selecting candidate EQ-5D bolt-ons.

PURPOSE: 'Bolt-on' dimensions are additional items added to multi-attribute utility instruments (MAUIs) such as EQ-5D that measure constructs not included in the core descriptive system. The use of bolt-ons has been proposed to improve the content validity and responsiveness of the descriptive system in certain settings and health conditions. EQ-5D bolt-ons serve a particular purpose and thus satisfy a certain set of criteria. The aim of this paper is to propose a set of criteria to guide the development, assessment and selection of candidate bolt-on descriptors. METHODS: Criteria were developed using an iterative approach. First, existing criteria were identified from the literature including those used to guide the development of MAUIs, the COSMIN checklist and reviews of existing bolt-ons. Second, processes used to develop bolt-ons based on qualitative and quantitative approaches were considered. The information from these two stages was formalised into draft development and selection criteria. These were reviewed by the project team and iteratively refined. RESULTS: Overall, 23 criteria for the development, assessment and selection of candidate bolt-ons were formulated. Development criteria focused on issues relating to i) structure, ii) language, and iii) consistency with the existing EQ-5D dimension structure. Assessment and selection criteria focused on face and content validity and classical psychometric indicators. CONCLUSION: The criteria generated can be used to guide the development of bolt-ons across different health areas. They can also be used to assess existing bolt-ons, and inform their inclusion in studies and patient groups where the EQ-5D may lack content validity.

Meta-research: justifying career disruption in funding applications, a survey of Australian researchers.

Background: When researchers' careers are disrupted by life events - such as illness or childbirth - they often need to take extended time off. This creates a gap in their research output that can reduce their chances of winning funding. In Australia, applicants can disclose their career disruptions and peer reviewers are instructed to make appropriate adjustments. However, it is not clear if and how applicants use career disruption sections or how reviewers adjust and if they do it consistently. Methods: To examine career disruption, we used surveys of the Australian health and medical research community. We used both a random sample of Australian authors on PubMed and a non-random convenience sample. Results: Respondents expressed concerns that sharing information on career disruption would harm their chances of being funded, with 13% saying they have medical or social circumstances but would not include it in their application, with concerns about appearing 'weak'. Women were more reluctant to include disruption. There was inconsistency in how disruption was adjusted for, with less time given for those with depression compared with caring responsibilities, and less time given for those who did not provide medical details of their disruption. Conclusions: The current system is likely not adequately adjusting for career disruption and this may help explain the ongoing funding gap for senior women in Australia. Funding: National Health and Medical Research Council Senior Research Fellowship (Barnett).

Science is an expensive endeavor. To pursue their ideas, most researchers need to win funding by submitting applications to highly competitive schemes with low success rates. Funding decisions depend on many factors, but usually take into consideration a researcher's track record: publications, collaborations with other researchers and even other awards they have received. Researchers whose careers have been disrupted by life events, including childbearing or being ill, may have a gap in their track record that reduces their chances of winning funding. Historically, female researchers have experienced career disruptions more often, leading to a funding gap between male and female researchers. To increase fairness and reduce this gap, many funding agencies have instructed the peer reviewers ­ other scientists ­ who assess funding applications to adjust their scores to account for career disruptions. However, large funding gaps are still frequently observed between female and male researchers. Barnett et al. wanted to know how career disruption is considered in practice by establishing what personal details are shared in applications by researchers with disruption, and how reviewers treat this information. To find out, they surveyed medical researchers in Australia and asked them for their views on career disruption as both funding applicants and reviewers of funding applications. The answers to the survey indicated that 13% of the applicants responding had experienced career disruptions, but would not include them in funding applications. In many cases, this reluctance to disclose career disruptions was due to concerns that it would harm an applicant's chances of winning funding, a concern that was greater in the women who responded to the survey. Researchers who answered the survey would claim less time off on average if their career disruption was for severe depression compared with caring for a child or elderly relative. Additionally, the answers to the survey show that, on average, peer reviewers ­ the scientists who assessed the applications ­ would give more time off to applicants who provided details about the medical issues that caused a career disruption than to those who did not. The results of this survey suggest that changes in the systems used to apply for funding and in how applications are assessed could make funding fairer. One suggestion would be to modify funding applications to make disruptions easier to report. Another would be to make changes to the reviewing procedures to increase privacy and reduce variability in how disruption is assessed. Changes in these directions could help researchers gain access to funding more fairly, increasing the quality and output of scientific research.

Midwives and Liability: Results of the 2018 National Midwives and Liability Survey.

INTRODUCTION: This is the third national survey about the incidence of midwifery involvement in malpractice litigation, case outcome, methods of coping, and the influence of fear of liability or actual litigation on midwifery practice and professional liability insurance. Incidence of disciplinary action was also included. METHODS: A link to a web-based survey was sent to all American College of Nurse-Midwives members with an active email address in January 2018. Students and associate members were excluded from analysis. Logistic regression was used to identify predictors of involvement in lawsuit. RESULTS: Of 6199 email links sent, 880 midwives responded (14%). One-third of participants (n = 280, 32%) have been named in at least one lawsuit after a median of 7 years in practice. Claims most often involved intrapartum hospital-based care and resulted from fetal heart rate interpretation. The most common outcome of a case was settlement prior to court or arbitration (n = 117, 42%). Significant predictors of litigation included older age of the midwife and region of practice (increased in Northeastern states, decreased in Midwestern states). Midwives' most common source of emotional support was their attorney. Only 6% (n = 53) of participants experienced disciplinary action against their state license. Half of the actions by a state governing board were unrelated to a lawsuit. DISCUSSION: Midwives may experience litigation the longer they are in practice, but there has not been a significant change in the incidence since the previous survey in 2009. More resources and education are needed for midwives to provide adequate peer support to colleagues following adverse events or when named in a lawsuit. Continued education is also needed for midwives regarding types of professional liability insurance, affordability, and how policy terms and limits influence clinical practice.

American College of Nurse-Midwives Clinical Bulletin Number 18: Induction of Labor.

Induction of labor is an increasingly common component of intrapartum care in the United States. This rise is fueled by a nationwide escalation in both medically indicated and elective inductions at or beyond term, supported by recent research showing some benefits of induction over expectant management. However, induction of labor medicalizes the birth experience and may lead to a complex cascade of interventions. The purpose of this Clinical Bulletin is twofold: (1) to guide clinicians on the use of person-centered decision-making when discussing induction of labor and (2) to review evidence-based practice recommendations for intrapartum midwifery care during labor induction.

A cross sectional study of organizational factors and their impact on job satisfaction and emotional burnout in a group of Australian nurses: infection control practitioners.

BACKGROUND: Infection control practitioners (ICPs) are a group of specialized nurses fundamental to effective healthcare infection prevention and control initiatives. Relative to other groups of nurses much less is known about their working conditions. Organizational factors may impact ICPs' levels of job dissatisfaction and emotional job burnout and, subsequently, their quality of practice. We measure a range of organizational factors to document the working conditions of ICPs and show how these are linked to job satisfaction and emotional burnout in a sample of Australian ICPs. METHODS: We conducted a cross sectional study using an online survey. All employed ICPs in 50 of the largest public hospitals in Australia were invited to participate. One hundred and fifty three ICPs completed the survey. RESULTS: ICPs are moderately to highly satisfied with their job but show high levels of emotional burnout, time pressure and cognitive demands. Low job satisfaction was associated with less job control, low perceived organizational support and poor communication. In contrast, emotional burnout was associated with high time pressure and cognitive demands coupled with poor communication. DISCUSSION: This study provides new evidence about the organizational context of ICPs in Australia, and about the factors that impact on job satisfaction and emotional burnout. These findings may be used to modify national infection prevention and control programs to suit local organizational contexts. Further research is needed to determine the precise nature of these relationships and the downstream impacts on hospital-wide infection control outcomes. CONCLUSIONS: Organizational context and factors are important to consider when evaluating the impact and implementation of infection control programs.

Review of Evidence-Based Methods for Successful Labor Induction.

Induction of labor is increasingly a common component of the intrapartum care. Knowledge of the current evidence on methods of labor induction is an essential component of shared decision-making to determine which induction method meets an individual's health needs and personal preferences. This article provides a review of the current research evidence on labor induction methods, including cervical ripening techniques, and contraction stimulation techniques. Current evidence about expected duration of labor following induction, use of the Bishop score to guide induction, and guidance on the use of combination methods for labor induction are reviewed.

Improving Nurse Self-Efficacy and Increasing Continuous Labor Support With the Promoting Comfort in Labor Safety Bundle.

OBJECTIVE: To increase nurse self-efficacy and the use of continuous labor support and to reduce the rate of primary cesareans among nulliparous women with low-risk pregnancies by implementing the Promoting Comfort in Labor safety bundle. DESIGN: A quality improvement project with a pre-post practice implementation design. This practice change was part of the Reducing Primary Cesarean Learning Collaborative from the American College of Nurse-Midwives. SETTING: A Level II regional hospital in Virginia with more than 2,600 births annually. Births are attended by certified nurse-midwives and physicians. PARTICIPANTS: Nursing staff on the labor and delivery unit in March 2016 (n = 27), September 2017 (n = 20), and June 2019 (n = 24). INTERVENTION/MEASUREMENTS: We updated policies, educated nurses, procured labor support equipment, and modified documentation of care. We measured nurse confidence and skill in labor support techniques with the Self-Efficacy Labor Support Scale over 4 years. We tracked how many women were provided continuous labor support and the primary cesarean birth rate among women who were nulliparous and low risk. RESULTS: Nurses' mean self-efficacy scores increased from 76.67 in 2016 to 86.96 in 2019 (p < .001). The proportion of women who were provided continuous labor support increased from a baseline of 4.38% (47/1,074) in January 2015 through March 2016 to 18.06% (82/454) in July through December 2019 (p < .001). The primary cesarean birth rate for nulliparous women with low-risk pregnancies remained stable, at approximately 18% from 2015 to 2019. CONCLUSION: Implementation of the Comfort in Labor Safety Bundle improved nurse self-efficacy in labor support techniques and increased the frequency of continuous labor support.

Patient-Reported Experiences After Hysterectomy: A Cross-Sectional Study of the Views of Over 2300 Women.

OBJECTIVE: To evaluate women's experiences after hysterectomy and predictors of their contentment and regret with the surgical approaches. METHODS: Cross-sectional, Patient-Reported Experience Measures survey in 2319 Australian women aged 21 to 90 years (median age of 52 years) who had received hysterectomy in the preceding 2 years. RESULTS: Overall, the vast majority of women (>96%) did not regret having had the hysterectomy. Women who received an open abdominal hysterectomy reported slower recovery with about 7% of women still not fully recovered after 12 months compared to those whose surgery was through a less invasive approach. Women who reported no adverse events, having been given a choice of type of hysterectomy, women who received an alternative to open abdominal hysterectomy, and women who felt prepared for discharge from hospital were significantly more likely to be content with their hysterectomy and report positive patient experiences. CONCLUSIONS: Compared with those who received a less invasive approach to hysterectomy, women who received open surgery were more likely to express negative experiences relating to their hospital stay and recovery from surgery. The results inform future improvements of care for women planning a hysterectomy.

Effectiveness of a structured, framework-based approach to implementation: the Researching Effective Approaches to Cleaning in Hospitals (REACH) Trial.

BACKGROUND: Implementing sustainable practice change in hospital cleaning has proven to be an ongoing challenge in reducing healthcare associated infections. The purpose of this study was to develop a reliable framework-based approach to implement and quantitatively evaluate the implementation of evidence-based practice change in hospital cleaning. DESIGN/METHODS: The Researching Effective Approaches to Cleaning in Hospitals (REACH) trial was a pragmatic, stepped-wedge randomised trial of an environmental cleaning bundle implemented in 11 Australian hospitals from 2016 to 2017. Using a structured multi-step approach, we adapted the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to support rigorous and tailored implementation of the cleaning bundle intervention in eleven diverse and complex settings. To evaluate the effectiveness of this strategy we examined post-intervention cleaning bundle alignment calculated as a score (an implementation measure) and cleaning performance audit data collected using ultraviolet (UV) gel markers (an outcome measure). RESULTS: We successfully implemented the bundle and observed improvements in cleaning practice and performance, regardless of hospital size, intervention duration and contextual issues such as staff and organisational readiness at baseline. There was a positive association between bundle alignment scores and cleaning performance at baseline. This diminished over the duration of the intervention, as hospitals with lower baseline scores were able to implement practice change successfully. CONCLUSION: Using a structured framework-based approach allows for pragmatic and successful implementation of clinical trials across diverse settings, and assists with quantitative evaluation of practice change. TRIAL REGISTRATION: Australia New Zealand Clinical Trial Registry ACTRN12615000325505, registered on 4 September 2015.

Cost-effectiveness of an Environmental Cleaning Bundle for Reducing Healthcare-associated Infections.

BACKGROUND: Healthcare-associated infections (HAIs) remain a significant patient safety issue, with point prevalence estimates being ~5% in high-income countries. In 2016-2017, the Researching Effective Approaches to Cleaning in Hospitals (REACH) study implemented an environmental cleaning bundle targeting communication, staff training, improved cleaning technique, product use, and audit of frequent touch-point cleaning. This study evaluates the cost-effectiveness of the environmental cleaning bundle for reducing the incidence of HAIs. METHODS: A stepped-wedge, cluster-randomized trial was conducted in 11 hospitals recruited from 6 Australian states and territories. Bundle effectiveness was measured by the numbers of Staphylococcus aureus bacteremia, Clostridium difficile infection, and vancomycin-resistant enterococci infections prevented in the intervention phase based on estimated reductions in the relative risk of infection. Changes to costs were defined as the cost of implementing the bundle minus cost savings from fewer infections. Health benefits gained from fewer infections were measured in quality-adjusted life-years (QALYs). Cost-effectiveness was evaluated using the incremental cost-effectiveness ratio and net monetary benefit of adopting the cleaning bundle over existing hospital cleaning practices. RESULTS: Implementing the cleaning bundle cost $349 000 Australian dollars (AUD) and generated AUD$147 500 in cost savings. Infections prevented under the cleaning bundle returned a net monetary benefit of AUD$1.02 million and an incremental cost-effectiveness ratio of $4684 per QALY gained. There was an 86% chance that the bundle was cost-effective compared with existing hospital cleaning practices. CONCLUSIONS: A bundled, evidence-based approach to improving hospital cleaning is a cost-effective intervention for reducing the incidence of HAIs.

Applying an Implementation Framework to the Use of Evidence from Economic Evaluations in Making Healthcare Decisions.

BACKGROUND AND OBJECTIVE: There is a need for the application of theory in understanding the use of evidence from economic evaluations in healthcare decision making. The purpose of this study is to review the published literature on the use of evidence from economic evaluations for healthcare decision making and to map the findings to the Consolidated Framework for Implementation Research (CFIR). METHODS: A systematic search strategy was used to identify studies investigating the factors that determine the use of evidence from economic evaluation in healthcare decision making. Barriers and facilitators identified in the included studies were mapped across the five CFIR domains, with the "intervention" referring to the use of economic evaluations in decision making. Gaps, inconsistencies and emergent relations were identified through the mapping process. RESULTS: Fifty-three studies met eligibility criteria and were included in the review. The CFIR constructs associated with the Intervention Characteristics and those associated with the knowledge and beliefs of users of economic evaluations were widely cited in the identified barriers and facilitators. Other constructs from the CFIR had not been reported in the literature, such as 'organisational networks' and 'individual stage of change'. Most of the stages in the implementation process as described by the CFIR were reflected in the identified barriers and facilitators. DISCUSSION: By categorising barriers and facilitators into domains, the CFIR provides a systematic approach to assess how these factors interact. Literature gaps in the literature regarding the use of economic evaluation in healthcare decision making were identified, specifically issues regarding organisational networks and the role of feedback. CONCLUSIONS: Through mapping findings from studies of the use of evidence from economic evaluations in healthcare decision making, we present an implementation framework based on the CFIR for understanding the use of economic evaluations into practice.

An environmental cleaning bundle and health-care-associated infections in hospitals (REACH): a multicentre, randomised trial.

BACKGROUND: The hospital environment is a reservoir for the transmission of microorganisms. The effect of improved cleaning on patient-centred outcomes remains unclear. We aimed to evaluate the effectiveness of an environmental cleaning bundle to reduce health care-associated infections in hospitals. METHODS: The REACH study was a pragmatic, multicentre, randomised trial done in 11 acute care hospitals in Australia. Eligible hospitals had an intensive care unit, were classified by the National Health Performance Authority as a major hospital (public hospitals) or having more than 200 inpatient beds (private hospitals), and had a health-care-associated infection surveillance programme. The stepped-wedge design meant intervention periods varied from 20 weeks to 50 weeks. We introduced the REACH cleaning bundle, a multimodal intervention, focusing on optimising product use, technique, staff training, auditing with feedback, and communication, for routine cleaning. The primary outcomes were incidences of health-care-associated Staphylococcus aureus bacteraemia, Clostridium difficile infection, and vancomycin-resistant enterococci infection. The secondary outcome was the thoroughness of cleaning of frequent touch points, assessed by a fluorescent marking gel. This study is registered with the Australian and New Zealand Clinical Trial Registry, number ACTRN12615000325505. FINDINGS: Between May 9, 2016, and July 30, 2017, we implemented the cleaning bundle in 11 hospitals. In the pre-intervention phase, there were 230 cases of vancomycin-resistant enterococci infection, 362 of S aureus bacteraemia, and 968 C difficile infections, for 3 534 439 occupied bed-days. During intervention, there were 50 cases of vancomycin-resistant enterococci infection, 109 of S aureus bacteraemia, and 278 C difficile infections, for 1 267 134 occupied bed-days. After the intervention, vancomycin-resistant enterococci infections reduced from 0·35 to 0·22 per 10 000 occupied bed-days (relative risk 0·63, 95% CI 0·41-0·97, p=0·0340). The incidences of S aureus bacteraemia (0·97 to 0·80 per 10 000 occupied bed-days; 0·82, 0·60-1·12, p=0·2180) and C difficile infections (2·34 to 2·52 per 10 000 occupied bed-days; 1·07, 0·88-1·30, p=0·4655) did not change significantly. The intervention increased the percentage of frequent touch points cleaned in bathrooms from 55% to 76% (odds ratio 2·07, 1·83-2·34, p<0·0001) and bedrooms from 64% to 86% (1·87, 1·68-2·09, p<0·0001). INTERPRETATION: The REACH cleaning bundle was successful at improving cleaning thoroughness and showed great promise in reducing vancomycin-resistant enterococci infections. Our work will inform hospital cleaning policy and practice, highlighting the value of investment in both routine and discharge cleaning practice. FUNDING: National Health and Medical Research Council (Australia).

Clinician perspectives of policy implementation: A qualitative study of the implementation of a national infection prevention policy in Australian hospitals.

BACKGROUND: Clinicians play an essential role in the implementation of infection prevention policy. Despite this, little is known about how infection control policy is implemented at an organizational level or what factors influence this process. In this study, we explore these factors and the policy implementation process in the context of the introduction of a national large-scale, government-directed infection prevention policy in Australia. METHODS: Focus groups with infection control professionals were held in 3 states to investigate the perspectives of infection control professionals involved in the implementation of aseptic technique policy requirements in Australian hospitals. Data were analyzed using an interpretive description approach, with themes mapped to the Consolidated Framework for Implementation Research. RESULTS: Common contextual factors were identified across all levels of the healthcare system that influenced implementation of the infection control policy, including external factors associated with the policy itself and the regulatory nature of government-directed policy. CONCLUSIONS: This study suggests that there may be particular constructs and contextual factors that are specific to policy implementation in the hospital setting. A better understanding of these factors and their influence on policy implementation would present an opportunity for improved implementation planning, resource allocation, and more effective policy development.

Surgical approach to hysterectomy and barriers to using minimally invasive methods.

Minimally invasive approaches to hysterectomy have been shown to be safe, effective and have recovery advantages over open hysterectomy, yet in Australia 36% of hysterectomies are still conducted by open surgery. In 2006, a survey of Australian gynaecological specialists found the main impediment to increasing laparoscopic hysterectomy to be a lack of surgical skills training opportunities. We resurveyed specialists to explore contemporary factors influencing surgeons' approaches to hysterectomy; 258 (estimated ~19%) provided analysable responses. Despite >50% of surveyed specialists wishing to practise laparoscopic hysterectomy in the future, lack of surgical skills, arising from the lack of training opportunities, remains the main impediment.

Changes in knowledge and attitudes of hospital environmental services staff: The Researching Effective Approaches to Cleaning in Hospitals (REACH) study.

BACKGROUND: The Researching Effective Approaches to Cleaning in Hospitals (REACH) study tested a multimodal cleaning intervention in Australian hospitals. This article reports findings from a pre/post questionnaire, embedded into the REACH study, that was administered prior to the implementation of the intervention and at the conclusion of the study. METHODS: A cross-sectional questionnaire, nested within a stepped-wedge trial, was administered. The REACH intervention was a cleaning bundle comprising 5 interdependent components. The questionnaire explored the knowledge, reported practice, attitudes, roles, and perceived organizational support of environmental services staff members in the hospitals participating in the REACH study. RESULTS: Environmental services staff members in 11 participating hospitals completed 616 pre- and 307 post-test questionnaires (n = 923). Increases in knowledge and practice were seen between the pre-and post-test questionnaires. Minimal changes were observed in attitudes regarding the role of cleaning and in perceived organizational support. CONCLUSION: To our knowledge, this is the first study to report changes in knowledge, attitudes, and perceived organizational support in environmental services staff members, in the context of a large multicenter clinical trial. In this underexplored group of hospital workers, findings suggest that environmental services staff members have a high level of knowledge related to cleaning practices and understand the importance of their role.

Factors influencing women's decision making in hysterectomy.

OBJECTIVE: To explore factors influencing how well-informed women felt about hysterectomy, influences on their decision making, and on them receiving a less-invasive alternative to open surgery. METHODS: Online questionnaire, conducted in 2015-2016, of women who had received a hysterectomy in Australia, in the preceding two years. RESULTS: Questionnaires were completed by 2319/6000 women (39% response). Most women (n=2225; 96%) felt well-informed about hysterectomy. Women were more aware of the open abdominal approach (n=1798; 77%), than of less-invasive vaginal (n=1552; 67%), laparoscopic (n=1540; 66%), laparoscopic-assisted (n=1303; 56%), and robotic approaches (n=289; 12%). Most women (n=1435; 62%) reported their gynaecologist was the most influential information source. Women who received information about hysterectomy from a GP (OR=1.47; 95% CI 1.15-1.90), or from a gynaecologist (OR=1.3; 95% CI 1.06-1.58), were more likely to feel better informed (p<0.01). CONCLUSION: This study is important because it helps clinicians, researchers and health policy makers to understand why many women still receive an open abdominal approach despite many learned societies recommending to avoid it if possible. PRACTICE IMPLICATIONS: Additional information, or education about avoiding open abdominal approach where possible may lead to a greater number of women receiving less-invasive types of hysterectomy in the future.

Antibiotic prescribing in primary healthcare: Dominant factors and trade-offs in decision-making.

BACKGROUND: This study aims to establish dominant factors influencing general practitioner (GP) decision-making on antibiotic prescribing in the Australian primary healthcare sector. Two research questions were posed: What influences antibiotic prescribing from the perspective of GPs? How do GPs trade-off on factors influencing antibiotic prescribing? METHODS: An exploratory sequential mixed methods design was used, comprising semi-structured interviews followed by a discrete choice experiment (DCE). Ten GPs practising in Brisbane and Greater Brisbane, Queensland were interviewed in September/October 2015. Interview data were used to develop the DCE, which was conducted online from July-October 2016. Twenty-three GPs participated in the DCE. RESULTS: Three main themes influencing antibiotic prescribing emerged from the semi-structured interviews: prescribing challenges, delayed antibiotic prescriptions, and patient expectations. From the DCE, "Duration of symptoms" and "Patient expectations" exerted the most influence on antibiotic prescribing. Taken together, these results suggest that key challenges to prudent antibiotic prescribing are: patient expectations, an important barrier which is surmountable; prescribing practices of medical colleagues, cultural memes and professional etiquette; and uncertainty of diagnosis coupled with patient expectations for antibiotics exert prescribing pressure on GPs. CONCLUSION: Patient expectation for antibiotics is the dominant modifiable factor influencing GP antibiotic prescribing behaviours. Key challenges to prudent antibiotic prescribing can be overcome through upskilling GPs to manage patient expectations efficaciously, and through two new emphases for public health campaigns-consumers have the power to reduce the use of antibiotics and the GP as a wise advocate for the patient.

Australian consumer perspectives, attitudes and behaviours on antibiotic use and antibiotic resistance: a qualitative study with implications for public health policy and practice.

BACKGROUND: Consumers receive over 27 million antibiotic prescriptions annually in Australian primary healthcare. Hence, consumers are a key group to engage in the fight against antibiotic resistance. There is a paucity of research pertaining to consumers in the Australian healthcare environment. This study aimed to investigate the perspectives, attitudes and behaviours of Australian consumers on antibiotic use and antibiotic resistance, to inform national programs for reducing inappropriate antibiotic consumption. METHOD: Semi-structured interviews with 32 consumers recruited via convenience and snowball sampling from a university population in South East Queensland. Interview transcripts were deductively and inductively coded. Main themes were identified using iterative thematic analysis. RESULTS: Three themes emerged from the analysis, to elucidate factors affecting antibiotic use: (a) prescription type; (b) consumer attitudes, behaviours, skills and knowledge; and (c) consumer engagement with antibiotic resistance. Consumers held mixed views regarding the use of delayed antibiotic prescriptions, and were often not made aware of the use of repeat antibiotic prescriptions. Consumers with regular general practitioners were more likely to have shared expectations regarding minimising the use of antibiotics. Even so, advice or information mediated by general practitioners was influential with all consumers; and helped to prevent inappropriate antibiotic use behaviours. Consumers were not aware of the free Return of Unwanted Medicines service offered by pharmacies and disposed of leftover antibiotics through household waste. To engage with mitigating antibiotic resistance, consumers required specific information. Previous public health campaigns raising awareness of antibiotics were largely not seen by this sample of consumers. CONCLUSIONS: Australian consumers have specific information needs regarding prescribed antibiotics to enable appropriate antibiotic use behaviours. Consumers also have expectations for high quality general practice consults conducted in a manner that increases consumer confidence in the treatment decision, regardless of whether an antibiotic is prescribed. To reduce inappropriate consumption of antibiotics and to more fully engage Australian consumers in mitigating antibiotic resistance, changes in health policy and practice are required.