Impact of high coverage of monovalent human rotavirus vaccine on Emergency Department presentations for rotavirus gastroenteritis.

INTRODUCTION: Australia was one of the first countries to introduce nationally funded rotavirus vaccination. The program has had a substantial impact on both rotavirus and all-cause acute gastroenteritis (AGE) hospitalisations and rotavirus laboratory tests. Evidence for an impact on Emergency Department (ED) presentations is limited. This study assessed changes in ED presentations for rotavirus in children aged <5 years in New South Wales, Australia, following introduction of monovalent human rotavirus vaccine (RV1, Rotarix(®), GlaxoSmithKline Australia Pty Ltd., Victoria, Australia). METHOD: A time series analysis to examine trends in total non-admitted ED presentations for all-cause AGE and in the rotavirus-attributable fraction using data on rotavirus positive laboratory tests. RESULTS: A decline in the rate of non-admitted ED presentations for all-cause AGE was observed for all ages, being most notable in 1 year old children. Compared with the pre-vaccination period, we estimated the average weekly rate was lower across the first 4.5 years of the program for both all-cause AGE (18.3%; 70.5 versus 57.5 per 100,000 population) and rotavirus attributable (55.4%; 17.3 versus 7.7 per 100,000 population) presentations. In the fourth year of the program, estimated annual rotavirus attributable presentations were 77% lower than the pre-vaccination annual mean (996 versus 4300 per year). CONCLUSION: The program was associated with a substantial decline in rotavirus attributable non-admitted AGE presentations to ED among children aged <5 years.

Beliefs and beyond: what can we learn from qualitative studies of lay people's understandings of cancer risk?

BACKGROUND: Clinicians and public health professionals are centrally concerned with mediating risk. However, people often resist the risk-related information that is communicated to them by experts, or have their own models of risk that conflict with expert views. Quantitative studies have clearly demonstrated the importance of health beliefs and various cognitive and emotional processes in shaping risk perception. More recently, a growing body of qualitative research has emerged, exploring lay conceptualizations, experiences and constructions of cancer risk. To date, this literature has not been synthesized. OBJECTIVE: We report the findings of a synthesis of qualitative literature regarding the ways in which lay people construct and experience cancer risk. DESIGN: We identified 87 articles and used the method of 'thematic synthesis' to identify and interpret key concepts from existing studies. RESULTS: Eight analytic categories were developed: (i) perceptions of risk factors; (ii) process of risk perception; (iii) seeking control and taking responsibility (motivational factors); (iv) experiencing cancer directly; (v) constructing risk temporally; (vi) embodying risk; (vii) identifying with risk; and (viii) constructing risk in a social context. CONCLUSIONS: Qualitative enquiry can provide us with a rich and nuanced picture of the ways in which people understand, experience and construct risk and how being 'at risk' is managed, and can assist us in our communication with both individual patients and populations.

Helping women make choices about mammography screening: an online randomized trial of a decision aid for 40-year-old women.

OBJECTIVE: To evaluate the effect of a decision aid (DA) on women's knowledge of the benefits and harms of screening and on their ability to make an informed decision. METHODS: An online randomized controlled trial among 321 women aged 38-45 years was conducted. Participants were randomized to either immediate or delayed access to the online DA which (i) explained the benefits and harms, (ii) included a values clarification exercise and a worksheet to support decision making. The primary outcome, knowledge of benefits and harms of screening, and secondary outcomes, informed choice (composite of knowledge, values and intention), anxiety and acceptability of the DA were measured using online questionnaires. RESULTS: Women in the intervention group were more knowledgeable (mean score out of 10, 7.35 vs 6.27, p<0.001) and were more likely to have made a decision (82% vs 61% p<0.001). Of those who made a decision, women in the intervention group were less likely to start screening now (52% vs 65% p=0.05). There was no significant difference in the proportion of women who made an informed choice (71% intervention group vs 64% control group, p=0.24). The DA was helpful, balanced and clear, and did not make women anxious. CONCLUSIONS: The DA increased knowledge and reduced indecision, without increasing feelings of anxiety. PRACTICE IMPLICATIONS: This decision aid is easy to access online and could be an inexpensive way of supporting women aged 40 who are considering whether to start screening now, or wait until they are 50. The results of this study demonstrate the potential of DAs to help inform women about both the benefits and risks of screening at this age and to support women and clinicians in this decision making process.

Writing social determinants into and out of cancer control: an assessment of policy practice.

A large literature concurs that social determinants of health (SDH) are demonstrable, important, and insufficiently attended to in policy and practice. A resulting priority for research should be to determine how the social determinants of health can best be addressed. In this paper we support the more effective transfer of social determinants research into policy by: (1) describing a qualitative analysis of thirty-two cancer control policy documents from six English-speaking OECD countries and two transnational organizations, demonstrating great variability in the treatment of social determinants in these policies; (2) critiquing these various policy practices in relation to their likely impact on social determinants of health; and (3) advancing a tool that policy writers can use to assess the way in which social determinants of health have been addressed in their work. In the sample of policy documents, the distinction between structural and intermediate determinants, population-based and targeted interventions, and their respective relationships to equity were not always clear. The authors identified four approaches to social determinants (acknowledging SDH, auditing SDH, stating aims regarding SDH and setting out actions on SDH), and five ways of writing about the relationship between social determinants and cancer risk. These five discourses implied, respectively: that group membership was intrinsically risky; that not enough was known about SDH; that risk arose from choices made by individuals; that groups were constrained by circumstance; or that structural change was necessary. Socio-cultural factors were generally presented negatively, though New Zealand policies modeled a possible alternative. Based on their empirical work, the authors propose a matrix and a set of questions to guide the development and assessment of health policy.

The impact of different criteria for selecting information to be provided to women undergoing diagnostic breast tests.

OBJECTIVE: To determine if the content of written information for women undergoing diagnostic breast tests would change depending on the criteria used to decide what information should be included. METHODS: Questionnaire study eliciting the views of advocates, breast physicians, breast surgeons, general practitioners, people with an interest in ethics, and women who had undergone breast tests on information that should be provided to women undergoing diagnostic breast tests. Different criteria were used to determine what information should be included in the written information. RESULTS: Advocates, breast physicians, breast surgeons, general practitioners, people with an interest in ethics, and women who had undergone breast tests held significantly different views about the importance of specific information items for women undergoing tests. Different methods of resolving these differences in views lead to the inclusion of different information in patient information material. CONCLUSION: This study highlights the practical necessity for guidelines for developing written information to include details about how to resolve differences in opinions about what information should be included in patient material. PRACTICE IMPLICATIONS: Further research is needed to determine the most appropriate way to decide the content of written information. In the meantime, developers of written patient information need to be cognizant of the effects of their decisions on the content of patient information.

Informed choice in mammography screening: a randomized trial of a decision aid for 70-year-old women.

BACKGROUND: Many women who have participated in mammography screening are now approaching 70 years of age. These women are advised to consider both the benefits and harms of continuing to be screened. Doing so may be difficult for individual women, and there are no evaluated decision support tools to assist them. METHODS: To assess the effect of a decision aid (DA) about whether to continue or stop mammography screening for women aged 70 years, a population-based, randomized controlled trial was conducted in New South Wales, Australia. Women aged 70 years who had regularly participated in mammography screening were eligible to participate in the trial. Women received a DA providing balanced, quantitative information or standard information available from the screening program. The main outcomes were the percentage of women making an informed choice about whether to continue or stop screening and the percentage of women participating in the screening. RESULTS: Women who received the DA (the intervention group) were better informed than the control group (mean increase in knowledge score out of 10, 2.62 for the intervention group vs 0.68 for the control group; P < .001), and a significantly greater percentage made an informed choice (73.5% vs 48.8%; P < .001). The DA did not increase anxiety and slightly reduced decisional conflict. There was no difference in the percentage of women who participated in screening within 1 month. CONCLUSIONS: This DA increased knowledge and assisted women to make an informed choice. It did not alter participation in screening. The DA is an effective way to assist women to make a decision about continuing mammography screening and seems to be a feasible intervention within a population screening program.

A one-item question with a Likert or Visual Analog Scale adequately measured current anxiety.

OBJECTIVE: To determine whether a single question with a Likert Scale or a Visual Analog Scale (VAS) response adequately measures current anxiety. STUDY DESIGN AND SETTING: Consecutive English-speaking adult women attending a dedicated breast clinic in a major Australian city were invited to complete a demographic questionnaire, the State Trait Anxiety Inventory (STAI), and a single question with a five-point Likert Scale response and a VAS in random order. Only women who completed the STAI were included in analyses. RESULTS: Four hundred of 497 (80%) eligible women agreed to participate. Both measures were adequate predictors of the STAI score; correlation with STAI was 0.78 (95% confidence interval [CI] 0.73-0.82) for the VAS and 0.75 (95% CI 0.70-0.79) for the Likert Scale. However, 11% of women incorrectly completed the VAS limiting its usefulness. CONCLUSION: A single question with either a Likert Scale or VAS response may be an adequate replacement for the STAI. Both measures quickly and easily assess anxiety and may be useful for research purposes when researchers have very limited time or questionnaire space or need to reduce the burden on participants of completing many measures.

A systematic review on communicating with patients about evidence.

OBJECTIVE: To conduct a systematic search for (1) the effectiveness of evidence-based communication tools to increase patient understanding of evidence, (2) effective formats for representing probabilistic information and (3) effective strategies for eliciting patient preferences about evidence. A case scenario is used to illustrate some of the difficulties of putting these results into practice. DATA SOURCES: Systematic search of The Cochrane Library, Medline, Psychinfo, Embase and Cancerlit. REVIEW METHODS: Systematic reviews of randomized controlled trials (RCTs) and high quality RCTs were included. Studies were excluded if they did not address the question, were focused on behavioural outcomes without attempting to increase understanding, were concerned with counselling as a therapeutic intervention, or were specific to communication regarding clinical trial participation. RESULTS: We found 10 systematic reviews of RCTs and 30 additional RCTs addressing our questions. Communication tools in most formats (verbal, written, video, provider-delivered, computer-based) will increase patients' understanding but are more likely to do so if structured, tailored and/or interactive. Probabilistic information is best represented as event rates (natural frequencies) in relevant groups of people, rather than words, probabilities or summarized as effect measures such as relative risk reduction. Illustrations such as cartoons, or graphs (vertical bar charts) appear to aid understanding. Values clarification exercises may be better than standard utility techniques for eliciting preferences in individual decision making. Looking for effective evidence-based communication tools for prostatic specific antigen testing highlighted the challenges for clinicians and consumers in accessing tools that are evidence-based in design as well as content. CONCLUSION: There is an increasing body of evidence supporting the design of effective evidence-based communication tools but variable access to such tools in practice.

Qualitative study of how women define and use information about breast symptoms and diagnostic tests.

Unstructured interviews were conducted with 14 women with recent experience of diagnostic testing to explore the definition and role of information in women's experiences of undergoing diagnostic breast tests. Analysis showed that women see information as more than what they are told by healthcare professionals. Information also comes from significant others, administration and reception staff, media, comparison with previous breast symptoms, silences, gestures and behavior of healthcare professionals and significant others, and the number of tests they undergo. Information is about more than understanding. It can provide support and control, reduce anxiety, facilitate question asking and promote women's trust and confidence in themselves and their healthcare professionals. Healthcare professionals need to be aware that women define information more broadly than what they are told, and of the importance women attach to this other information. They also need to be aware that information serves more purposes than helping women understand the diagnostic testing process and their result.

An exploratory study of cancer patients' views on doctor-provided and independent written prognostic information.

This is the first study to systematically compare cancer patients' views on prognostic information provided by their doctor and written prognostic information obtained from a major cancer organisation (The Cancer Council New South Wales). Twenty-six adult patients who were recruited from a cancer clinic and an oncologist's private rooms completed a questionnaire and an interview. Participants varied in their views about the relative accuracy of doctor-provided and independent written information and responses to contradictory information. Participants' need for certainty, trust in their doctor and concerns about the effect of undermining that trust, appear to influence whether they would discuss independent information with their doctor, and how they would deal with conflicting information. Although preliminary, this study has identified a number of issues that may need to be taken into account both by people developing written prognostic information and by doctors, who may need to address patient concerns about trust to assist patients to deal with conflicting information.

Women's preferences for and views on decision-making for diagnostic tests.

It is unclear whether the Control Preferences Scale (CPS) provides a suitable framework for eliciting women's preferences for involvement in decision-making about diagnostic tests. The aims of this study were to assess the appropriateness of the role label approach for eliciting preferences for decision-making about diagnostic tests and to elicit women's preferences for, and views about, decision-making for diagnostic tests. In-depth, face-to-face, semi-structured interviews were conducted with 37 women who had previously participated in a population-based telephone survey. Analysis of the interview transcripts revealed that qualitative questions may be a more sensitive methodology for eliciting preferences than the role label approach as exemplified by the CPS. The analysis identified a number of issues associated with decision-making for diagnostic tests, including defining what a decision is, the rationale for the preference and factors that influence the preferred role such as the perceived seriousness of the test and potential outcomes. The role label approach used to elicit preferences for involvement in decision-making may be too simplistic. It may not fully capture the complexity of women's thoughts about test decision-making, including how they define a decision and what factors affect their preference.

Consumer information materials for diagnostic breast tests: women's views on information and their understanding of test results.

OBJECTIVES: To explore women's views on diagnostic breast test information and elicit their preferences for this information. DESIGN: In-depth, face-to-face interview. SETTING AND PARTICIPANTS: Thirty-seven women who had previously participated in a population-based telephone survey. MAIN OUTCOME MEASURES: Qualitative thematic analysis. RESULTS: Analysis of interview transcripts revealed information about: (1) the wide range of information participants wanted about diagnostic mammography; (2) general reactions to diagnostic breast test information, including positive and negative reactions, views of test accuracy information and perceived influences on information preferences; (3) preferences for information content and presentation including the need for written information, the meaning of statistical information, different views on a simple presentation style, and variation in preferences; and (4) women's understanding of diagnostic test results. CONCLUSION: Women want a range of information about diagnostic mammography, which is relevant at different times in the decision-making and testing process. Many women have difficulty interpreting test results.

Medical tests: women's reported and preferred decision-making roles and preferences for information on benefits, side-effects and false results.

OBJECTIVE: To determine women's preferences for and reported experience with medical test decision-making. DESIGN: Computer-assisted telephone survey. SETTING AND PARTICIPANTS: Six hundred and fifty-two women resident in households randomly selected from the New South Wales electronic white pages. MAIN OUTCOME MEASURES: Reported and preferred test and treatment (for comparison) decision-making, satisfaction with and anxiety about information on false results and side-effects; and effect of anxiety on desire for such information. RESULTS: Overall most women preferred to share test (94.6%) and treatment (91.2%) decision-making equally with their doctor, or to take a more active role, with only 5.4-8.9% reporting they wanted the doctor to make these decisions on their behalf. This pattern was consistent across all age groups. In general, women reported experiencing a decision-making role that was consistent with their preference. Women who had a usual doctor were more likely to report experiencing an active role in decision-making. More women reported receiving as much information as they wanted about the benefits of tests and treatment than about the side-effects of tests and treatment. Most women wanted information about the possibility of false test results (91.5%) and test side-effects (95.6%), but many reported the doctor never provided this information (false results = 40.0% and side-effects = 31.3%). A substantial proportion said this information would make them anxious (false results = 56.6% and side-effects = 43.1%), but reported they wanted the information anyway (false results = 77.6% and side-effects = 88.1%). CONCLUSIONS: Women prefer an active role in test and treatment decision-making. Many women reported receiving inadequate information. If so, this may jeopardize informed decision-making.