Cost-effectiveness of a pragmatic exercise intervention for women with breast cancer: results from a randomized controlled trial.

OBJECTIVE: To report on the cost-effectiveness of the Exercise for Health trial, comparing an exercise intervention with usual care during and following treatment for women with breast cancer. METHODS: Women with breast cancer were randomized to an 8-month exercise intervention (involving regular contact with an exercise physiologist over the phone, n = 67, or home delivered face to face, n = 67) or usual care (n = 60) group and were assessed pre-intervention (5 weeks post-surgery), mid-intervention (6 months post-surgery), and 10 weeks post-intervention (12 months post-surgery). The benefit measures were "number of improvers" in quality of life (FACT-B+4) and quality-adjusted life years (QALYs). Data on provider, patient, and government costs were used to consider 2 cost scenarios: (1) a service provider model and (2) a private model. RESULTS: There were 69 improvers in the intervention group compared with 21 in the usual care group (odds ratio 2.09, 95% confidence interval 1.08, 4.01; P = .033). The incremental cost per improver was A$2282 to A$2644. Quality-adjusted life years gain for the intervention group versus the usual care group was 0.009, with incremental cost per QALY gain for models 1 and 2 being A$105 231 and A$90 842, respectively. However, sensitivity analyses indicate that incremental cost per QALY gained was volatile to EuroQol-5D-3L weights. CONCLUSIONS: Findings suggest that a pragmatic exercise intervention yields more women with markedly improved quality of life after breast cancer than usual care and may be cost-effective. The results are less certain in terms of incremental cost per quality-adjusted life years; however, this may be an inappropriate measure for reflecting exercise benefit for women with breast cancer.

Weight and weight change following breast cancer: evidence from a prospective, population-based, breast cancer cohort study.

BACKGROUND: While weight gain following breast cancer is considered common, results supporting these findings are dated. This work describes changes in body weight following breast cancer over 72 months, compares weight with normative data and explores whether weight changes over time are associated with personal, diagnostic, treatment or behavioral characteristics. METHODS: A population-based sample of 287 Australian women diagnosed with early-stage invasive breast cancer was assessed prospectively at six, 12, 18 and 72 months post-surgery. Weight was clinically measured and linear mixed models were used to explore associations between weight and participant characteristics (collected via self-administered questionnaire). Those with BMI changes of one or more units were considered to have experienced clinically significant changes in weight. RESULTS: More than half (57%) of participants were overweight or obese at 6 months post-surgery, and by 72 months post-surgery 68% of women were overweight or obese. Among those who gained more weight than age-matched norms, clinically significant weight gain between 6 and 18 months and 6 and 72 months post-surgery was observed in 24% and 39% of participants, respectively (median [range] weight gain: 3.9 kg [2.0-11.3 kg] and 5.2 kg [0.6-28.7], respectively). Clinically-significant weight losses were observed in up to 24% of the sample (median [range] weight loss between 6 and 72 months post-surgery: -6.4 kg [-1.9--24.6 kg]). More extensive lymph node removal, being treated on the non-dominant side, receiving radiation therapy and lower physical activity levels at 6 months was associated with higher body weights post-breast cancer (group differences >3 kg; all p < 0.05). CONCLUSIONS: While average weight gain among breast cancer survivors in the long-term is small, subgroups of women experience greater gains linked with adverse health and above that experienced by age-matched counterparts. Weight change post-breast cancer is a contemporary public health issue and the integration of healthy weight education and support into standard breast cancer care has potential to significantly improve the length and quality of cancer survivorship.

Prevalence and risk factors for foot and ankle musculoskeletal disorders experienced by nurses.

BACKGROUND: Nurses are at high risk of musculoskeletal disorders (MSDs). Although the prevalence of MSDs of the lower back, upper limbs, neck and shoulders have been reported previously in nursing, few studies have evaluated MSDs of the foot and ankle. This study evaluated the prevalence of foot and ankle MSDs in nurses and their relation to individual and workplace risk factors. METHODS: A self-administered survey incorporating the Nordic Musculoskeletal Questionnaire (NMQ) was distributed, over a nine-week period, to all eligible nurses (n = 416) working in a paediatric hospital in Brisbane, Australia. The prevalence of MSDs for each of the NMQ body regions was determined. Bivariate and multivariable logistic regression analyses were conducted to examine the relationships between activity-limiting foot/ankle MSDs and risk factors related to the individual (age, body mass index, number of existing foot conditions, smoking history, general physical health [SF36 Physical Component Scale], footwear features) or the workplace (level of nursing position, work location, average hours worked, hours worked in previous week, time since last break from work). RESULTS: A 73% response rate was achieved with 304 nurses completing surveys, of whom 276 were females (91%). Mean age of the nurses was 37 years (±10), younger than the state average of 43 years. Foot/ankle MSDs were the most prevalent conditions experienced by nurses during the preceding seven days (43.8%, 95% CI 38.2-49.4%), the second most prevalent MSDs to impair physical activity (16.7%, 95% CI 13.0-21.3%), and the third most prevalent MSD, after lower-back and neck problems, during the preceding 12 months (55.3%, 95% CI 49.6-60.7%). Of the nurse and work characteristics investigated, obesity, poor general physical health, existing foot conditions and working in the intensive care unit emerged as statistically significant (p < 0.05) independent risk factors for activity-limiting foot/ankle MSDs. CONCLUSIONS: Foot/ankle MSDs are common in paediatric hospital nurses and resulted in physical activity limitations in one out of every six nurses. We recommend targeted education programs regarding the prevention, self-management and treatment strategies for foot/ankle MSDs. Further research is needed into the impact of work location and extended shift durations on foot/ankle MSDs.

Child eating behavior outcomes of an early feeding intervention to reduce risk indicators for child obesity: the NOURISH RCT.

OBJECTIVE: The objective was to describe parent-reported child eating behavior and maternal parenting impact outcomes of an infant feeding intervention to reduce child obesity risk. METHODS: An assessor masked Randomized Controlled Trial (RCT) with concealed allocation of individual mother-infant dyads. The NOURISH RCT enrolled 698 first-time mothers (mean age 30.1 years, SD = 5.3) with healthy term infants (51% female) aged 4.3 months (SD = 1.0) at baseline. Outcomes were assessed 6 months post-intervention when the children were 2 years old. Mothers reported on child eating behaviors using the Children's Eating Behavior Questionnaire (CEBQ), food preferences, and dietary intake using a 24-hour telephone recall. Parenting was assessed using five scales validated for use in Australia. RESULTS: Intervention effects were evident on the CEBQ overall (MANOVA P = 0.002) and 4/8 subscales: child satiety responsiveness (P = 0.03), fussiness (P = 0.01), emotional overeating (P < 0.01), and food responsiveness (P = 0.06). Intervention children "liked" more fruits (P < 0.01) and fewer non-core foods and beverages (P = 0.06, 0.03). The intervention mothers reported greater "autonomy encouragement" (P = 0.002). CONCLUSIONS: Anticipatory guidance on protective feeding practices appears to have modest positive impacts on child eating behaviors that are postulated to reduce future obesity risk.

Outcomes of an early feeding practices intervention to prevent childhood obesity.

OBJECTIVE: The goal of this study was to evaluate outcomes of a universal intervention to promote protective feeding practices that commenced in infancy and aimed to prevent childhood obesity. METHODS: The NOURISH randomized controlled trial enrolled 698 first-time mothers (mean ± SD age: 30.1 ± 5.3 years) with healthy term infants (51% female) aged 4.3 ± 1.0 months at baseline. Mothers were randomly allocated to self-directed access to usual care or to attend two 6-session interactive group education modules that provided anticipatory guidance on early feeding practices. Outcomes were assessed 6 months after completion of the second information module, 20 months from baseline and when the children were 2 years old. Maternal feeding practices were self-reported by using validated questionnaires and study-developed items. Study-measured child height and weight were used to calculate BMI z scores. RESULTS: Retention at follow-up was 78%. Mothers in the intervention group reported using responsive feeding more frequently on 6 of 9 subscales and 8 of 8 items (all, P ≤ .03) and overall less controlling feeding practices (P < .001). They also more frequently used feeding practices (3 of 4 items; all, P < .01) likely to enhance food acceptance. No statistically significant differences were noted in anthropometric outcomes (BMI z score: P = .10) nor in prevalence of overweight/obesity (control 17.9% vs intervention 13.8%; P = .23). CONCLUSIONS: Evaluation of NOURISH data at child age 2 years found that anticipatory guidance on complementary feeding, tailored to developmental stage, increased use by first-time mothers of "protective" feeding practices that potentially support the development of healthy eating and growth patterns in young children.

Maternal report of young children's eating styles. Validation of the Children's Eating Behaviour Questionnaire in three ethnically diverse Australian samples.

The aim of this study was to validate the Children's Eating Behaviour Questionnaire (CEBQ) in three ethnically and culturally diverse samples of mothers in Australia. Confirmatory factor analysis utilising structural equation modelling examined whether the established 8-factor model of the CEBQ was supported in our three populations: (i) a community sample of first-time mothers allocated to the control group of the NOURISH trial (mean child age=24months [SD=1]; N=244); (ii) a sample of immigrant Indian mothers of children aged 1-5years (mean age=34months [SD=14]; N=203), and (iii) a sample of immigrant Chinese mothers of children aged 1-4years (mean age=36months [SD=14]; N=216). The original 8-factor model provided an acceptable fit to the data in the NOURISH sample with minor post hoc re-specifications (two error covariances on Satiety Responsiveness and an item-factor covariance to account for a cross-loading of an item (Fussiness) on Satiety Responsiveness). The re-specified model showed reasonable fit in both the Indian and Chinese samples. Cronbach's α estimates ranged from .73 to .91 in the Australian sample and .61-.88 in the immigrant samples. This study supports the appropriateness of the CEBQ in the multicultural Australian context.

Exercise for health: a randomized, controlled trial evaluating the impact of a pragmatic, translational exercise intervention on the quality of life, function and treatment-related side effects following breast cancer.

Exercise for Health was a randomized, controlled trial designed to evaluate two modes of delivering (face-to-face [FtF] and over-the-telephone [Tel]) an 8-month translational exercise intervention, commencing 6-weeks post-breast cancer surgery (PS). Outcomes included quality of life (QoL), function (fitness and upper body) and treatment-related side effects (fatigue, lymphoedema, body mass index, menopausal symptoms, anxiety, depression and pain). Generalised estimating equation modelling determined time (baseline [5 weeks PS], mid-intervention [6 months PS], post-intervention [12 months PS]), group (FtF, Tel, Usual Care [UC]) and time-by-group effects. 194 women representative of the breast cancer population were randomised to the FtF (n = 67), Tel (n = 67) and UC (n = 60) groups. There were significant (p < 0.05) interaction effects on QoL, fitness and fatigue with differences being observed between the treatment groups and the UC group. Trends observed for the treatment groups were similar. The treatment groups reported improved QoL, fitness and fatigue over time and changes observed between baseline and post-intervention were clinically relevant. In contrast, the UC group experienced no change, or worsening QoL, fitness and fatigue, mid-intervention. Although improvements in the UC group occurred by 12-months post-surgery, the change did not meet the clinically relevant threshold. There were no differences in other treatment-related side effects between groups. This translational intervention trial, delivered either FtF or Tel, supports exercise as a form of adjuvant breast cancer therapy that can prevent declines in fitness and function during treatment and optimise recovery post-treatment.

Identification of cancer-related symptom clusters: an empirical comparison of exploratory factor analysis methods.

CONTEXT: Symptom clusters, important for symptom management strategies, have been determined empirically by various analytical methods. Guidance to select methods from the options available in standard statistical packages is limited. OBJECTIVES: To compare alternative common factor analysis (FA) extraction methods appropriate to the data, to assess whether or not they determine similar symptom clusters, and to propose analytical approaches that are useful in this clinical context. METHODS: Within one month of commencing chemotherapy, outpatients from oncology and hematology clinics (n = 202) reported their symptom experience on a modified Rotterdam Symptom Checklist. Symptom distress levels in the past week were rated on a scale of one (not at all) to four (very much). In a secondary data analysis of 42 symptoms, the associations between symptoms and factors were determined using alternative common FA methods: principal axis factoring, unweighted least squares, image factor analysis, and alpha factor analysis (AFA). Symptom inclusion in a cluster was based on the interpretation of pattern and structure coefficients, and importantly, clinical relevance of the grouping. RESULTS: Five symptom clusters were commonly identified across methods: musculoskeletal discomforts/lethargy, oral discomforts, upper gastrointestinal discomforts, vasomotor symptoms, and gastrointestinal toxicities. In AFA, three additional clusters were lethargy, somatic symptoms, and treatment-related symptom clusters. CONCLUSION: The most parsimonious solution resulted from principal axis factoring, but for large numbers of symptoms, AFA may be superior by identifying symptom clusters more useful for symptom management. Interpreting complex symptom relationships may lead to the investigation of pathophysiological mechanisms and intervention opportunities. Future studies should include psychological and cognitive symptoms.

Cancer-related symptom clusters for symptom management in outpatients after commencing adjuvant chemotherapy, at 6 months, and 12 months.

GOALS OF WORK: The aim of this secondary data analysis was to investigate symptom clusters over time for symptom management of a patient group after commencing adjuvant chemotherapy. MATERIALS AND METHODS: A prospective longitudinal study of 219 cancer outpatients conducted within 1 month of commencing chemotherapy (T1), 6 months (T2), and 12 months (T3) later. Patients' distress levels were assessed for 42 physical symptoms on a clinician-modified Rotterdam Symptom Checklist. Symptom clusters were identified in exploratory factor analyses at each time. Symptom inclusion in clusters was determined from structure coefficients. Symptoms could be associated with multiple clusters. Stability over time was determined from symptom cluster composition and the proportion of symptoms in the initial symptom clusters replicated at later times. MAIN RESULTS: Fatigue and daytime sleepiness were the most prevalent distressing symptoms over time. The median number of concurrent distressing symptoms approximated 7, over time. Five consistent clusters were identified at T1, T2, and T3. An additional two clusters were identified at 12 months, possibly due to less variation in distress levels. Weakness and fatigue were each associated with two, four, and five symptom clusters at T1, T2, and T3, respectively, potentially suggesting different causal mechanisms. CONCLUSION: Stability is a necessary attribute of symptom clusters, but definitional clarification is required. We propose that a core set of concurrent symptoms identifies each symptom cluster, signifying a common cause. Additional related symptoms may be included over time. Further longitudinal investigation is required to identify symptom clusters and the underlying causes.

Determinants of rapid weight gain during infancy: baseline results from the NOURISH randomised controlled trial.

BACKGROUND: Rapid weight gain in infancy is an important predictor of obesity in later childhood. Our aim was to determine which modifiable variables are associated with rapid weight gain in early life. METHODS: Subjects were healthy infants enrolled in NOURISH, a randomised, controlled trial evaluating an intervention to promote positive early feeding practices. This analysis used the birth and baseline data for NOURISH. Birthweight was collected from hospital records and infants were also weighed at baseline assessment when they were aged 4-7 months and before randomisation. Infant feeding practices and demographic variables were collected from the mother using a self administered questionnaire. Rapid weight gain was defined as an increase in weight-for-age Z-score (using WHO standards) above 0.67 SD from birth to baseline assessment, which is interpreted clinically as crossing centile lines on a growth chart. Variables associated with rapid weight gain were evaluated using a multivariable logistic regression model. RESULTS: Complete data were available for 612 infants (88% of the total sample recruited) with a mean (SD) age of 4.3 (1.0) months at baseline assessment. After adjusting for mother's age, smoking in pregnancy, BMI, and education and infant birthweight, age, gender and introduction of solid foods, the only two modifiable factors associated with rapid weight gain to attain statistical significance were formula feeding [OR = 1.72 (95%CI 1.01-2.94), P = 0.047] and feeding on schedule [OR = 2.29 (95%CI 1.14-4.61), P = 0.020]. Male gender and lower birthweight were non-modifiable factors associated with rapid weight gain. CONCLUSIONS: This analysis supports the contention that there is an association between formula feeding, feeding to schedule and weight gain in the first months of life. Mechanisms may include the actual content of formula milk (e.g. higher protein intake) or differences in feeding styles, such as feeding to schedule, which increase the risk of overfeeding. TRIAL REGISTRATION: Australian Clinical Trials Registry ACTRN12608000056392.

Prevalence and prognostic significance of secondary lymphedema following breast cancer.

BACKGROUND: The adverse consequences of lymphedema following breast cancer in relation to physical function and quality of life are clear; however, its potential relationship with survival has not been investigated. Our purpose was to determine the prevalence of lymphedema and associated upper-body symptoms at 6 years following breast cancer and to examine the prognostic significance of lymphedema with respect to overall 6-year survival (OS). METHODS AND RESULTS: A population-based sample of Australian women (n = 287) diagnosed with invasive, unilateral breast cancer was followed for a median of 6.6 years and prospectively assessed for lymphedema (using bioimpedance spectroscopy [BIS], sum of arm circumferences [SOAC], and self-reported arm swelling), a range of upper-body symptoms, and vital status. OS was measured from date of diagnosis to date of death or last follow-up. Kaplan-Meier methods were used to calculate OS and Cox proportional hazards models quantified the risk associated with lymphedema. Approximately 45% of women had reported at least one moderate to extreme symptom at 6.6 years postdiagnosis, while 34% had shown clinical evidence of lymphedema, and 48% reported arm swelling at least once since baseline assessment. A total of 27 (9.4%) women died during the follow-up period, and lymphedema, diagnosed by BIS or SOAC between 6-18 months postdiagnosis, predicted mortality (BIS: HR = 2.5; 95% CI: 0.9, 6.8, p = 0.08; SOAC: 3.0; 95% CI: 1.1, 8.7, p = 0.04). There was no association (HR = 1.2; 95% CI: 0.5, 2.6, p = 0.68) between self-reported arm swelling and OS. CONCLUSIONS: These findings suggest that lymphedema may influence survival following breast cancer treatment and warrant further investigation in other cancer cohorts and explication of a potential underlying biology.

Lymphedema after breast or gynecological cancer: use and effectiveness of mainstream and complementary therapies.

OBJECTIVES: The purpose of this study was to describe the use, as well as perceived effectiveness, of mainstream and complementary and alternative medicine (CAM) therapies in the treatment of lymphedema following breast or gynecological cancer. Further, the study assessed the relationship between the characteristics of lymphedema (including type, severity, stability, and duration), and the use of CAM and/or mainstream treatment. METHODS: This was a cross-sectional study using a convenience sample of women with lymphedema following breast and gynecological cancers. A self-administered questionnaire was sent to 247 potentially eligible women. Of those returned (50%), 23 were ineligible and 6 were excluded due to level of missing data. RESULTS: In the previous 12 months, the majority of women (90%) had used mainstream treatments to treat their lymphedema, with massage being the most commonly used (86%). One (1) in 2 women had used CAM to treat their lymphedema, and 98% of those using CAM were also using mainstream treatments. Over 27 types of CAM were reported, with use of a chi machine, vitamin E supplements, yoga, and meditation being the most commonly reported forms. The perceived effectiveness ratings (1-7 with 7=completely effective) of mainstream (mean±standard deviation (SD): 5.3±1.5) and CAM therapies (mean±SD: 5.2+1.6) were considered high. CONCLUSIONS: These results demonstrate that mainstream and CAM treatment use is common, varied, and considered to be effective among women with lymphedema following breast or gynecological cancer. Furthermore, it highlights the immediate need for larger prospective studies assessing the inter-relationship between the use of mainstream and CAM therapies for treatment success.

Design and implementation of the Exercise for Health trial -- a pragmatic exercise intervention for women with breast cancer.

BACKGROUND: Exercise for Health was a pragmatic, randomised, controlled trial comparing the effect of an eight-month exercise intervention on function, treatment-related side effects and quality of life following breast cancer, compared with usual care. The intervention commenced six weeks post-surgery, and two modes of delivering the same intervention was compared with usual care. The purpose of this paper is to describe the study design, along with outcomes related to recruitment, retention and representativeness, and intervention participation. METHODS: Women newly diagnosed with breast cancer and residing in a major metropolitan city of Queensland, Australia, were eligible to participate. Consenting women were randomised to a face-to-face-delivered exercise group (FtF, n = 67), telephone-delivered exercise group (Tel, n = 67) or usual care group (UC, n = 60) and were assessed pre-intervention (5-weeks post-surgery), mid-intervention (6 months post-surgery) and 10 weeks post-intervention (12 months post-surgery). Each intervention arm entailed 16 sessions with an Exercise Physiologist. RESULTS: Of 318 potentially eligible women, 63% (n = 200) agreed to participate, with a 12-month retention rate of 93%. Participants were similar to the Queensland breast cancer population with respect to disease characteristics, and the randomisation procedure was mostly successful at attaining group balance, with the few minor imbalances observed unlikely to influence intervention effects given balance in other related characteristics. Median participation was 14 (min and max: 0 and 16) and 13 (min and max: 3 and 16) intervention sessions for the FtF and Tel, respectively, with 68% of those in Tel and 82% in FtF participating in at least 75% of sessions. DISCUSSION: Participation in both intervention arms during and following treatment for breast cancer was feasible and acceptable to women. Future work, designed to inform translation into practice, will evaluate the quality of life, clinical, psychosocial and behavioural outcomes associated with each mode of delivery.

Patterns, correlates, and prognostic significance of quality of life following breast cancer.

OBJECTIVE: To describe quality of life (QOL) over a 12-month period among women with breast cancer, consider the association between QOL and overall survival (OS), and explore characteristics associated with QOL declines. METHODS: A population-based sample of Australian women (n=287) with invasive, unilateral breast cancer (Stage I+) was observed prospectively for a median of 6.6 years. QOL was assessed at 6, 12, and 18 months post-diagnosis, using the Functional Assessment of Cancer Therapy, Breast (FACT-B+4) questionnaire. Raw scores for the FACT-B+4 and subscales were computed and individuals were categorized according to whether QOL declined, remained stable or improved between 6 and 18 months. Kaplan-Meier and Cox proportional hazards survival methods were used to estimate OS and its associations with QOL. Logistic regression models identified factors associated with QOL decline. RESULTS: Within FACT-B+4 subscales, between 10% and 23% of women showed declines in QOL. Following adjustment for established prognostic factors, emotional well-being and FACT-B+4 scores at 6 months post-diagnosis were associated with OS (p<0.05). Declines in physical (p<0.01) or functional (p=0.02) well-being between 6 and 18 months post-diagnosis were also associated significantly with OS. Receiving multiple forms of adjuvant treatment, a perception of not handling stress well and reporting one or more other major life events at 6 months post-diagnosis were factors associated with declines in QOL in multivariable analyses. CONCLUSIONS: Interventions targeted at preventing QOL declines may ultimately improve quantity as well as quality of life following breast cancer.

Upper-body morbidity following breast cancer treatment is common, may persist longer-term and adversely influences quality of life.

BACKGROUND: Impairments in upper-body function (UBF) are common following breast cancer. However, the relationship between arm morbidity and quality of life (QoL) remains unclear. This investigation uses longitudinal data to describe UBF in a population-based sample of women with breast cancer and examines its relationship with QoL. METHODS: Australian women (n=287) with unilateral breast cancer were assessed at three-monthly intervals, from six- to 18-months post-surgery (PS). Strength, endurance and flexibility were used to assess objective UBF, while the Disability of the Arm, Shoulder and Hand questionnaire and the Functional Assessment of Cancer Therapy-Breast questionnaire were used to assess self-reported UBF and QoL, respectively. RESULTS: Although mean UBF improved over time, up to 41% of women revealed declines in UBF between six- and 18-months PS. Older age, lower socioeconomic position, treatment on the dominant side, mastectomy, more extensive lymph node removal and having lymphoedema each increased odds of declines in UBF by at least two-fold (p<0.05). Lower baseline and declines in perceived UBF between six- and 18-months PS were each associated with poorer QoL at 18-months PS (p<0.05). CONCLUSIONS: Significant upper-body morbidity is experienced by many following breast cancer treatment, persisting longer term, and adversely influencing the QoL of breast cancer survivors.

A validated self-administered female pelvic floor questionnaire.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to validate a self-administered version of the already validated interviewer-administered Australian pelvic floor questionnaire. METHODS: The questionnaire was completed by 163 women attending an urogynecological clinic. Face and convergent validity was assessed. Reliability testing and comparison with the interviewer-administered version was performed in a subset of 105 patients. Responsiveness was evaluated in a subset of 73 women. RESULTS: Missing data did not exceed 4% for any question. Cronbach's alpha coefficients were acceptable in all domains. Kappa coefficients for the test-retest analyses varied from 0.64-1.0. Prolapse symptoms correlated significantly with the pelvic organ prolapse quantification. Urodynamics confirmed the reported symptom stress incontinence in 70%. The self and interviewer-administered questionnaires demonstrated equivalence. Effect sizes ranged from 0.6 to 1.4. CONCLUSIONS: This self-administered pelvic floor questionnaire assessed pelvic floor function in a reproducible and valid fashion and due to its responsiveness, can be used for routine clinical assessment and outcome research.

Gynecological cancer survivors and community support services: referral, awareness, utilization and satisfaction.

OBJECTIVES: To quantify gynecological cancer survivors' referral to, awareness of, utilization of and satisfaction with community support services, as well as the factors associated with service use. METHODS: In 2004, 802 gynecological cancer survivors, 3 months-5 years post-diagnosis, completed a postal questionnaire (56% response rate). Descriptive statistics summarized outcome prevalences. Logistic regression models identified correlates of service utilization. RESULTS: Substantial proportions of women were aware of the main cancer support organization, Cancer Council Queensland (72%), and of information booklets (74%), helplines (66%), support groups (56%) and internet information (50%). Less than half were aware of other services. The most commonly used resources and services were information booklets (37%), the internet (23%), and helplines (20%). More broadly, 43% utilized information/internet support, 30% utilized psychosocial services and 27% utilized functional/practical services. Approximately one-fifth (19%) used more than one support types. Having a health-care provider referral, being diagnosed with lymphedema or living in northern Queensland were associated with higher odds of service use in all three of the support types. While most (86%) of those referred used a service, only a few women received referrals. Among users, satisfaction with services was high. CONCLUSIONS: While gynecological cancer survivors accessed a variety of support, there is a need to ensure women are aware of services. Given the low prevalence of referrals and that referral was a key influence on service use, clinician education may be necessary to improve service referral. Organizations should also consider strategies to keep services high on clinicians' radars.

The NOURISH randomised control trial: positive feeding practices and food preferences in early childhood - a primary prevention program for childhood obesity.

BACKGROUND: Primary prevention of childhood overweight is an international priority. In Australia 20-25% of 2-8 year olds are already overweight. These children are at substantially increased the risk of becoming overweight adults, with attendant increased risk of morbidity and mortality. Early feeding practices determine infant exposure to food (type, amount, frequency) and include responses (eg coercion) to infant feeding behaviour (eg. food refusal). There is correlational evidence linking parenting style and early feeding practices to child eating behaviour and weight status. A focus on early feeding is consistent with the national focus on early childhood as the foundation for life-long health and well being. The NOURISH trial aims to implement and evaluate a community-based intervention to promote early feeding practices that will foster healthy food preferences and intake and preserve the innate capacity to self-regulate food intake in young children. METHODS/DESIGN: This randomised controlled trial (RCT) aims to recruit 820 first-time mothers and their healthy term infants. A consecutive sample of eligible mothers will be approached postnatally at major maternity hospitals in Brisbane and Adelaide. Initial consent will be for re-contact for full enrolment when the infants are 4-7 months old. Individual mother- infant dyads will be randomised to usual care or the intervention. The intervention will provide anticipatory guidance via two modules of six fortnightly parent education and peer support group sessions, each followed by six months of regular maintenance contact. The modules will commence when the infants are aged 4-7 and 13-16 months to coincide with establishment of solid feeding, and autonomy and independence, respectively. Outcome measures will be assessed at baseline, with follow up at nine and 18 months. These will include infant intake (type and amount of foods), food preferences, feeding behaviour and growth and self-reported maternal feeding practices and parenting practices and efficacy. Covariates will include sociodemographics, infant feeding mode and temperament, maternal weight status and weight concern and child care exposure. DISCUSSION: Despite the strong rationale to focus on parents' early feeding practices as a key determinant of child food preferences, intake and self-regulatory capacity, prospective longitudinal and intervention studies are rare. This trial will be amongst to provide Level II evidence regarding the impact of an intervention (commencing prior to age 12 months) on children's eating patterns and behaviours. TRIAL REGISTRATION: ACTRN12608000056392.

Multivariate methods to identify cancer-related symptom clusters.

Multivariate methods are required to assess the interrelationships among multiple, concurrent symptoms. We examined the conceptual and contextual appropriateness of commonly used multivariate methods for cancer symptom cluster identification. From 178 publications identified in an online database search of Medline, CINAHL, and PsycINFO, limited to articles published in English, 10 years prior to March 2007, 13 cross-sectional studies met the inclusion criteria. Conceptually, common factor analysis (FA) and hierarchical cluster analysis (HCA) are appropriate for symptom cluster identification, not principal component analysis. As a basis for new directions in symptom management, FA methods are more appropriate than HCA. Principal axis factoring or maximum likelihood factoring, the scree plot, oblique rotation, and clinical interpretation are recommended approaches to symptom cluster identification.

Australian pelvic floor questionnaire: a validated interviewer-administered pelvic floor questionnaire for routine clinic and research.

The aim of this study was to design and validate an interviewer-administered pelvic floor questionnaire that integrates bladder, bowel and sexual function, pelvic organ prolapse, severity, bothersomeness and condition-specific quality of life. Validation testing of the questionnaire was performed using data from 106 urogynaecological patients and a separately sampled community cohort of 49 women. Missing data did not exceed 2% for any question. It distinguished community and urogynaecological populations regarding pelvic floor dysfunction. The bladder domain correlated with the short version of the Urogenital Distress Inventory, bowel function with an established bowel questionnaire and prolapse symptoms with the International Continence Society prolapse quantification. Sexual function assessment reflected scores on the McCoy Female Sexuality Questionnaire. Cronbach's alpha coefficients were acceptable in all domains. Kappa coefficients of agreement for the test-retest analyses varied from 0.5 to 1.0. The interviewer-administered pelvic floor questionnaire assessed pelvic floor function in a reproducible and valid fashion in a typical urogynaecological clinic.