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Bowel cancer kills over 4000 Australians each year. From the late 1980s to October 2005, research evidence guided the development of bowel cancer screening policy proposals, but political, financial and institutional constraints restricted implementation options. Since 2006, the Australian Government has provided a limited bowel cancer screening program, based on what the government deems it can afford, rather than on evidence of what is required to implement a successful population-based screening program. Even a partial program can be implemented in an evidence-based way, and failure to do so threatens to undermine the potential public health gains of a national bowel cancer screening program. To realise the expected public health gains from a national bowel cancer screening program, bowel cancer screening policy should return to its evidence-based beginnings, starting with an analysis of Australian age-specific cost-effectiveness data. [ABSTRACT FROM AUTHOR]

Introduction: This cluster-randomized controlled trial aimed to assess the effect of the "Which test is best?" tool on risk-appropriate screening (RAS) and colorectal cancer (CRC) screening uptake., Methods: General practices in Sydney and Melbourne, Australia, and a random sub-sample of 460 patients (aged 25-74 years) per practice were invited by post. Clusters were computer randomized independently of the researchers to an online CRC risk calculator with risk-based recommendations versus usual care. Primary and secondary outcomes were RAS and screening uptake via self-reported 5-year screening behaviour after 12 months follow-up. The usual care group (UCG) also self-reported 5-year CRC screening behaviour at 12 month post-randomization., Results: Fifty-six practices were randomized (27 to the intervention and 29 to the control, 55 practices participated) with 818 intervention and 677 controls completing the primary outcome measure. The intervention significantly increased RAS in high-risk participants compared with UCG (80.0% vs. 64.0%, respectively; OR = 3.14, 95% CI: 1.25-7.96) but not in average-risk (44.9% vs. 49.5%, respectively; OR = 0.97, 95% CI: 0.99-1.12) or moderate-risk individuals (67.9% vs. 81.1%, respectively; OR = 0.40, 95% CI: 0.12-1.33). Faecal occult blood testing uptake over 12 months was increased compared with the UCG (24.9% vs. 15.1%; adjusted OR = 1.66, 95% CI: 1.24-2.22), and there was a non-significant increase in colonoscopies during the same period (16.6% vs. 12.2%; adjusted OR = 1.42, 95% CI: 0.97-2.08)., Conclusion: An online CRC risk calculator with risk-based screening recommendations increased RAS in high-risk participants and improved screening uptake overall within a 12-month follow-up period. Such tools may be useful for facilitating the uptake of risk-based screening guidelines., (© 2022 The Author(s). Published by S. Karger AG, Basel.)

Background: Participation by patients in their own health care improves quality and safety. Question prompt lists (QPLs) can improve participation, particularly with doctors' endorsement. Few data have explored doctors' attitudes on these tools. We sought the experiences and attitudes of general practitioners and other specialists toward patient question asking and QPLs in their practice., Methods: In-depth, semistructured interviews and focus groups with purposively selected Australian doctors were conducted. Interview guides were used to explore doctors' experiences of patient question asking, patients' lists, and a sample QPL created using an Australian government-funded online tool, "Question Builder." Recordings were transcribed verbatim and data analyzed thematically using the method by Braun and Clarke., Results: Focus groups with 3 to 9 participants and a further 17 individual interviews were conducted. There was a total of 40 participants, 23 general practitioners and 17 other specialists (e.g., physicians, surgeons, pediatricians). Our analysis was summarized into several themes. 1) The doctors expected, encouraged, and had significant experience of patient question asking and patients' lists. They described many barriers for patients and their efforts to ensure patients had the information they needed. 2) The doctors felt responsible for creating an environment conducive to patient question asking, the delivery of answers, having strategies for unanswered questions, and balancing the agendas of both parties in the consultation. 3) Structured QPLs that prepared patients and facilitated the consultation agenda were viewed positively. The degree of time pressures participating doctors experienced in their context had a strong influence on how they responded to the sample QPL., Conclusion: Doctors in this study expected patients to ask questions and endorsed the benefits of QPLs. However, there were more diverse views about the feasibility of implementing them in practice. Designing QPLs to fit within current workflows, via more succinct and tailored designs, may result in wider doctor acceptance and endorsement, hence maximizing the benefits of QPLs with improved patient participation and patient safety.

Background: Shared decision making requires evidence to be conveyed to the patient in a way they can easily understand and compare. Patient decision aids facilitate this process. This article reviews the current evidence for how to present numerical probabilities within patient decision aids., Methods: Following the 2013 review method, we assembled a group of 9 international experts on risk communication across Australia, Germany, the Netherlands, the United Kingdom, and the United States. We expanded the topics covered in the first review to reflect emerging areas of research. Groups of 2 to 3 authors reviewed the relevant literature based on their expertise and wrote each section before review by the full authorship team., Results: Of 10 topics identified, we present 5 fundamental issues in this article. Although some topics resulted in clear guidance (presenting the chance an event will occur, addressing numerical skills), other topics (context/evaluative labels, conveying uncertainty, risk over time) continue to have evolving knowledge bases. We recommend presenting numbers over a set time period with a clear denominator, using consistent formats between outcomes and interventions to enable unbiased comparisons, and interpreting the numbers for the reader to meet the needs of varying numeracy., Discussion: Understanding how different numerical formats can bias risk perception will help decision aid developers communicate risks in a balanced, comprehensible manner and avoid accidental "nudging" toward a particular option. Decisions between probability formats need to consider the available evidence and user skills. The review may be useful for other areas of science communication in which unbiased presentation of probabilities is important.

Background: Decision aid developers have to convey complex task-specific numeric information in a way that minimizes bias and promotes understanding of the options available within a particular decision. Whereas our companion paper summarizes fundamental issues, this article focuses on more complex, task-specific aspects of presenting numeric information in patient decision aids., Methods: As part of the International Patient Decision Aids Standards third evidence update, we gathered an expert panel of 9 international experts who revised and expanded the topics covered in the 2013 review working in groups of 2 to 3 to update the evidence, based on their expertise and targeted searches of the literature. The full panel then reviewed and provided additional revisions, reaching consensus on the final version., Results: Five of the 10 topics addressed more complex task-specific issues. We found strong evidence for using independent event rates and/or incremental absolute risk differences for the effect size of test and screening outcomes. Simple visual formats can help to reduce common judgment biases and enhance comprehension but can be misleading if not well designed. Graph literacy can moderate the effectiveness of visual formats and hence should be considered in tool design. There is less evidence supporting the inclusion of personalized and interactive risk estimates., Discussion: More complex numeric information. such as the size of the benefits and harms for decision options, can be better understood by using incremental absolute risk differences alongside well-designed visual formats that consider the graph literacy of the intended audience. More research is needed into when and how to use personalized and/or interactive risk estimates because their complexity and accessibility may affect their feasibility in clinical practice.

Background: There is increasing interest in shared decision making (SDM) in Australia. Question prompt lists (QPLs) support question asking by patients, a key part of SDM. QPLs have been studied in a variety of settings, and increasingly the internet provides a source of suggested questions for patients. Environmental scans have been shown to be useful in assessing the availability and quality of online SDM tools., Objective: This study aimed to assess the number and readability of QPLs available to users via Google.com.au., Methods: Our environmental scan used search terms derived from literature and reputable websites to search for QPLs available via Google.com.au. Following removal of duplicates from the 4000 URLs and 22 reputable sites, inclusion and exclusion criteria were applied to create a list of unique QPLs. A sample of 20 QPLs was further assessed for list length, proxy measures of quality such as a date of review, and evidence of doctor endorsement. Readability of the sample QPL instructions and QPLs themselves was assessed using Flesch Reading Ease and Flesch-Kincaid Grade Level scores., Results: Our environmental scan identified 173 unique QPLs available to users. Lists ranged in length from 1 question to >200 questions. Of our sample, 50% (10/20) had a listed date of creation or update, and 60% (12/20) had evidence of authorship or source. Flesch-Kincaid Grade Level scores for instructions were higher than for the QPLs (grades 10.3 and 7.7, respectively). There was over a 1 grade difference between QPLs from reputable sites compared with other sites (grades 4.2 and 5.4, respectively)., Conclusions: People seeking questions to ask their doctor using Google.com.au encounter a vast number of question lists that they can use to prepare for consultations with their doctors. Markers of the quality or usefulness of various types of online QPLs, either surrogate or direct, have not yet been established, which makes it difficult to assess the value of the abundance of lists. Doctor endorsement of question asking has previously been shown to be an important factor in the effectiveness of QPLs, but information regarding this is not readily available online. Whether these diverse QPLs are endorsed by medical practitioners warrants further investigation., (©Marguerite Clare Tracy, Heather L Shepherd, Pinika Patel, Lyndal Jane Trevena. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 29.05.2020.)

Objectives: Question prompt lists (QPLs) are one strategy to increase patient participation in healthcare decisions but the extent to which consumers might access them in the 'real world' is largely unknown. This study measured usage of a passively-promoted, government-funded web-based patient-generated QPL tool, called Question Builder (Australia) (QB) hosted on healthdirect.gov.au, a consumer health information website., Methods: 12.5months of post-launch Google Analytics data from QB were analysed. Two existing coding frameworks (RIAS and ACEPP) were used to code QB questions thematically and 107 user-generated lists were analysed further to determine the questions chosen and prioritised., Results: QB was accessed 8915 times, 4000 question lists were commenced and 1271 lists completed. Most lists were for general practice (GP) consultations (2444) rather than specialist consultations (1556). The most frequently chosen question was "Do I need any tests?". Shared decision-making questions (SDM) made up 40% of questions prioritised e.g. "Do I need any treatment and what are my treatment options?", Conclusions: There is active use of this online QPL, with strong interest in creating lists for GP consultations. Question Builder users prioritised questions which facilitate SDM., Practice Implications: More research is required to assess the utilisation of QB in practice and health professionals' views of QB., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Purpose: To determine the effectiveness of patient decision aids when used with patients who face cancer-related decisions., Patients and Methods: Two reviewers independently screened the 105 trials in the original 2017 Cochrane review to identify eligible trials of patient decision aids across the cancer continuum. Primary outcomes were attributes of the choice and decision-making process. Secondary outcomes were patient behavior and health system effects. A meta-analysis was conducted for similar outcome measures., Results: Forty-six trials evaluated patient decision aids for cancer care, including 27 on screening decisions (59%), 12 on treatments (26%), four on genetic testing (9%), and three on prevention (6%). Common decisions were aboutprostate cancer screening (30%), colorectal cancer screening (22%), breast cancer treatment (13%), and prostate cancer treatment (9%). Compared with the control groups (usual care or alternative interventions), the patient decision aid group improved the match between the chosen option and the features that mattered most to the patient as demonstrated by improved knowledge (weighted mean difference, 12.88 of 100; 95% CI, 9.87 to 15.89; 24 trials), accurate risk perception (risk ratio [RR], 1.77; 95% CI, 1.22 to 2.56; six trials), and value-choice agreement (RR, 2.76; 95% CI, 1.57 to 4.84; nine trials). Compared with controls, the patient decision aid group improved the decision-making process with decreased decisional conflict (weighted mean difference, -9.56 of 100; 95% CI, -13.90 to -5.23; 12 trials), reduced clinician-controlled decision making (RR, 0.57; 95% CI, 0.41 to 0.79; eight trials), and fewer patients being indecisive (RR, 0.59; 95% CI, 0.45 to 0.78; nine trials)., Conclusion: Patient decision aids improve the attributes of the choice made and decision-making process for patients who face cancer-related decisions.

Objective: To determine the frequency of general practice administrative encounters, and to determine whether they represent low value care., Design: Secondary analysis of data from the Bettering Evaluation and Care of Health (BEACH) dataset., Setting: 1 568 100 GP-patient encounters in Australia, 2000-01 to 2015-16., Participants: An annual nationally representative random sample of about 1000 GPs, who each recorded the details of 100 consecutive encounters with patients., Main Outcome Measures: Proportions of general practice encounters that were potentially low value care encounters (among the patient's reasons for the encounter was at least one administrative, medication, or referral request) and potentially low value care only encounters (such reasons were the sole reason for the encounter). For 2015-16, we also examined other health care provided by GPs at these encounters., Results: During 2015-16, 18.5% (95% CI, 17.7-19.3%) of 97 398 GP-patient encounters were potentially low value care request encounters; 7.4% (95% CI, 7.0-7.9%) were potentially low value care only encounters. Administrative work was requested at 3.8% (95% CI, 3.5-4.0%) of GP visits, 35.4% of which were for care planning and coordination, 33.5% for certification, and 31.2% for other reasons. Medication requests were made at 13.1% (95% CI, 12.4-13.7%) of encounters; other health care was provided at 57.9% of medication request encounters, counselling, advice or education at 23.4%, and pathology testing was ordered at 16.7%. Referrals were requested at 2.8% (95% CI, 1.7-3.0%) of visits, at 69.4% of which additional health care was provided. The problems managed most frequently at potentially low value care only encounters were chronic diseases., Conclusion: Most patients requested certificates, medications and referrals in the context of seeking help for other health needs. Additional health care, particularly for chronic diseases, was provided at most GP administrative encounters. The MBS Review should consider the hidden value of these encounters.

Objectives: Few interventions have been designed that provide standardised information to primary care clinicians about the diagnostic and treatment recommendations resulting from cancer multidisciplinary team (MDT) (tumour board) meetings. This study aimed to develop, implement and evaluate a standardised template for lung cancer MDTs to provide clinical information and treatment recommendations to general practitioners (GPs). Specific objectives were to (1) evaluate template feasibility (acceptability, appropriateness and timeliness) with GPs and (2) document processes of preimplementation, implementation and evaluation within the MDT setting., Design: A mixed-method study design using structured interviews with GPs and qualitative documentation of project logs about implementation processes., Setting: Two hospitals in Central Sydney, New South Wales, Australia., Participants: 61 GPs evaluated the template. Two lung cancer MDTs, consisting of 33 clinicians, and eight researchers participated in template development and implementation strategy., Results: The MDT-reporting template appears to be a feasible way of providing clinical information to GPs following patient presentation at a lung cancer MDT meeting. Ninety-five per cent of GPs strongly agreed or agreed that the standardised template provided useful and relevant information, that it was received in a timely manner (90%) and that the information was easy to interpret and communicate to the patient (84%). Implementation process data show that the investment made in the preimplementation stage to integrate the template into standard work practices was a critical factor in successful implementation., Conclusions: This study demonstrates that it is feasible to provide lung cancer MDT treatment recommendations to GPs through implementation of a standardised template. A simple intervention, such as a standardised template, can help to address quality gaps and ensure that timely information is communicated between tertiary and primary care healthcare providers., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Increasingly, the experiences and perceptions of parents who decline vaccination are the subject of investigation. However, the experiences of clinicians who encounter these parents in the course of their work has received little academic attention to date. This study aimed to understand the challenges faced and strategies used when general practitioners and immunising nurses encounter parents who choose not to vaccinate their children., Methods: Primary care providers were recruited from regions identified through the Australian Childhood Immunisation Register (ACIR) as having higher than national average rates of registered objection to childhood vaccination. Interviews began with an exploration of provider experiences with parents who accept, are hesitant towards, and who decline vaccination. Participants were asked specifically about how they addressed any difficulties they encountered in their interactions. Thematic analysis focused on encounters with parents - challenges and strategies., Results: Twenty-six general practitioners (GPs), community and practice nurses (PNs) were interviewed across two regions in NSW, Australia. Providers' sense of professional identity as health advocates and experts became conflicted in their encounters with vaccine objecting parents. Providers were dissatisfied when such consultations resulted in a 'therapeutic roadblock' whereby provider-parent communication came to a standstill. There were mixed views about being asked to sign forms exempting parents from vaccinating their children. These ranged from a belief that completing the forms rewarded parents for non-conformity to seeing it as a positive opportunity for engagement. Three common strategies were employed by providers to navigate through these challenges; 1) to explore and inform, 2) to mobilise clinical rapport and 3) to adopt a general principle to first do no harm to the therapeutic relationship., Conclusions: Many healthcare providers find consultations with vaccine objecting parents challenging and some, particularly more experienced providers, employ successful strategies to address this. Primary care providers, especially those more junior, could benefit from additional communication guidance to better the outcome and increase the efficiency of their interactions with such parents.

Objective: To test the feasibility and assess the uptake and acceptability of implementing a consumer questions programme, AskShareKnow, to encourage consumers to use the questions '1. What are my options; 2. What are the possible benefits and harms of those options; 3. How likely are each of those benefits and harms to happen to me?' These three questions have previously shown important effects in improving the quality of information provided during consultations and in facilitating patient involvement., Methods: This single-arm intervention study invited participants attending a reproductive and sexual health-care clinic to view a 4-min video-clip in the waiting room. Participants completed three questionnaires: (T1) prior to viewing the intervention; (T2) immediately after their consultation; and (T3) two weeks later., Results: A total of 121 (78%) participants viewed the video-clip before their consultation. Eighty-four (69%) participants asked one or more questions, and 35 (29%) participants asked all three questions. For those making a decision, 55 (87%) participants asked one or more questions, while 27 (43%) participants asked all three questions. Eighty-seven (72%) participants recommended the questions. After two weeks, 47 (49%) of the participants recalled the questions., Conclusions: Enabling patients to view a short video-clip before an appointment to improve information and involvement in health-care consultations is feasible and led to a high uptake of question asking in consultations., Practice Implications: This AskShareKnow programme is a simple and feasible method of training patients to use a brief consumer-targeted intervention that has previously shown important effects in improving the quality of information provided during consultations and in facilitating patient involvement and use of evidence-based questions., (©2015 The Authors. Health Expectations published by John Wiley & Sons Ltd.)

Background: Making informed decisions about cancer screening involves understanding the benefits and harms in conjunction with personal values. There is little research examining factors associated with informed decision making or participation in screening in the context of a decision aid trial., Objectives: To identify factors associated with informed choice and participation in fecal occult blood testing (FOBT) among lower education populations., Design: Randomized controlled trial of an FOBT decision aid conducted between July and November 2008., Setting: Socioeconomically disadvantaged areas in New South Wales, Australia., Participants: Included 572 adults aged 55 to 64 years with lower education., Measurements: Sociodemographic variables, perceived health literacy, and involvement preferences in decision making were examined to identify predictors of informed choice (knowledge, attitudes, and behavior)., Results: Multivariate analysis identified independent predictors of making an informed choice as having higher education (relative risk [RR], 1.49; 95% confidence interval [CI], 1.13-1.95; P = 0.001), receiving the decision aid (RR, 2.88; 95% CI, 1.87-4.44; P < 0.001), and being male (RR, 1.48; 95% CI, 1.11-1.97; P = 0.009). Participants with no confidence in completing forms and poorer self-reported health were less likely to make an informed choice (RR, 0.74; 95% CI, 0.53-1.03; P = 0.05 and RR, 0.57; 95% CI, 0.36-0.89; P = 0.007, respectively). Independent predictors of completing the FOBT were positive screening attitudes, receiving the standard information, preference for making the decision alone, and knowing that screening may lead to false-positive/negative results., Limitations: We did not objectively measure health literacy., Conclusions: Participants with the lowest levels of education had greater difficulties making an informed choice about participation in bowel screening. Alternative methods are needed to support informed decision making among lower education populations., (© The Author(s) 2014.)

Shared decision making enables a clinician and patient to participate jointly in making a health decision, having discussed the options and their benefits and harms, and having considered the patient's values, preferences and circumstances. It is not a single step to be added into a consultation, but a process that can be used to guide decisions about screening, investigations and treatments. The benefits of shared decision making include enabling evidence and patients' preferences to be incorporated into a consultation; improving patient knowledge, risk perception accuracy and patient-clinician communication; and reducing decisional conflict, feeling uninformed and inappropriate use of tests and treatments. Various approaches can be used to guide clinicians through the process. We elaborate on five simple questions that can be used: What will happen if the patient waits and watches? What are the test or treatment options? What are the benefits and harms of each option? How do the benefits and harms weigh up for the patient? Does the patient have enough information to make a choice? Although shared decision making can occur without tools, various types of decision support tools now exist to facilitate it. Misconceptions about shared decision making are hampering its implementation. We address the barriers, as perceived by clinicians. Despite numerous international initiatives to advance shared decision making, very little has occurred in Australia. Consequently, we are lagging behind many other countries and should act urgently.

Background: Revitalising primary health care (PHC) and the need to reach MDG targets requires developing countries to adapt current evidence about effective health systems to their local context. Timor-Leste in one of the world's newest developing nations, with high maternal and child mortality rates, malaria, TB and malnutrition. Mountainous terrain and lack of transport pose serious challenges for accessing health services and implementing preventive health strategies., Methods: We conducted a non-systematic review of the literature and identified six components of an effective PHC system. These were mapped onto three countries' PHC systems and present a case study from Timor-Leste's Servisu Integrado du Saude Comunidade (SISCa) focussing on MDGs. Some of the challenges of implementing these into practice are shown through locally collected health system data., Results: An effective PHC system comprises 1) Strong leadership and government in human rights for health; 2) Prioritisation of cost-effective interventions; 3) Establishing an interactive and integrated culture of community engagement; 4) Providing an integrated continuum of care at the community level; 5) Supporting skilled and equipped health workers at all levels of the health system; 6) Creating a systems cycle of feedback using data to inform health care. The implementation case study from Timor-Leste (population 1 million) shows that in its third year, limited country-wide data had been collected and the SISCa program provided over half a million health interactions at the village level. However, only half of SISCa clinics were functional across the country. Attendances included not only pregnant women and children, but also adults and older community members. Development partners have played a key role in supporting this implementation process., Conclusion: The SISCa program is a PHC model implementing current best practice to reach remote communities in a new developing country. Despite limited resources, village level healthcare and engagement can be achieved but takes a long-term commitment and partnership.

Primary care providers have important roles across the cancer continuum, from encouraging screening and accurate diagnosis to providing care during and after treatment for both the cancer and any comorbid conditions. Evidence shows that higher cancer screening participation rates are associated with greater involvement of primary care. Primary care providers are pivotal in reducing diagnostic delay, particularly in health systems that have long waiting times for outpatient diagnostic services. However, so-called fast-track systems designed to speed up hospital referrals are weakened by significant variation in their use by general practitioners (GPs), and affect the associated conversion and detection rates. Several randomized controlled trials have shown primary care-led follow-up care to be equivalent to hospital-led care in terms of patient wellbeing, recurrence rates and survival, and might be less costly. For primary care-led follow-up to be successful, appropriate guidelines must be incorporated, clear communication must be provided and specialist care must be accessible if required. Finally, models of long-term cancer follow-up are needed that provide holistic care and incorporate management of co-morbid conditions. We discuss all these aspects of primary care, focusing on the most common cancers managed at the GP office-breast, colorectal, prostate, lung and cervical cancers.

Background: Making evidence-based decisions often requires comparison of two or more options. Research-based evidence may exist which quantifies how likely the outcomes are for each option. Understanding these numeric estimates improves patients' risk perception and leads to better informed decision making. This paper summarises current "best practices" in communication of evidence-based numeric outcomes for developers of patient decision aids (PtDAs) and other health communication tools., Method: An expert consensus group of fourteen researchers from North America, Europe, and Australasia identified eleven main issues in risk communication. Two experts for each issue wrote a "state of the art" summary of best evidence, drawing on the PtDA, health, psychological, and broader scientific literature. In addition, commonly used terms were defined and a set of guiding principles and key messages derived from the results., Results: The eleven key components of risk communication were: 1) Presenting the chance an event will occur; 2) Presenting changes in numeric outcomes; 3) Outcome estimates for test and screening decisions; 4) Numeric estimates in context and with evaluative labels; 5) Conveying uncertainty; 6) Visual formats; 7) Tailoring estimates; 8) Formats for understanding outcomes over time; 9) Narrative methods for conveying the chance of an event; 10) Important skills for understanding numerical estimates; and 11) Interactive web-based formats. Guiding principles from the evidence summaries advise that risk communication formats should reflect the task required of the user, should always define a relevant reference class (i.e., denominator) over time, should aim to use a consistent format throughout documents, should avoid "1 in x" formats and variable denominators, consider the magnitude of numbers used and the possibility of format bias, and should take into account the numeracy and graph literacy of the audience., Conclusion: A substantial and rapidly expanding evidence base exists for risk communication. Developers of tools to facilitate evidence-based decision making should apply these principles to improve the quality of risk communication in practice.

Background: The majority of women in rural India have poor or no access to cervical cancer screening services, although one-quarter of all cervical cancers in the world occur there. Several large trials have proven the efficacy of low-tech cervical cancer screening methods in the Indian context but none have documented the necessary components and processes of implementing this evidence in a low-resource setting., Methods: This paper discusses a feasible model of implementation of cervical cancer screening programme in low-resource settings developed through a pilot research project carried out in rural Tamilnadu, India. The programme used visual inspection of cervix after acetic acid application (VIA) as a screening tool, nurses in the primary care centres as the primary screeners and peer educators within Self-Help Women groups to raise community awareness., Results: The uptake of screening was initially low despite the access to a screening programme. However, the programme witnessed an incremental increase in the number of women accessing screening with increasing community awareness., Conclusions: The investigators recommend 4 key components to programme implementation in low-resource setting: 1) Evidence-based, cost-effective test and treatment available within the reach of the community; 2) Appropriate referral pathways; 3) Skilled health workers and necessary equipment; and 4) Optimisation of health literacy, beliefs, attitudes of the community.

Objective: To test the effect of three questions (what are my options? what are the benefits and harms? and how likely are these?), on information provided by physicians about treatment options., Methods: We used a cross-over trial using two unannounced standardized patients (SPs) simulating a presentation of mild-moderate depression. One SP was assigned the intervention role (asking the questions), the other the control role. An intervention and control SP visited each physician, order allocated randomly. The study was conducted in family practices in Sydney, Australia, during 2008-09. Data were obtained from consultation audio-recordings. Information about treatment options and patient involvement were analyzed using the Assessing Communication about Evidence and Patient Preferences (ACEPP) tool and the OPTION tool., Results: Thirty-six SP visits were completed (18 intervention, 18 control). Scores were higher in intervention consultations than controls: ACEPP scores 21.4 vs. 16.6, p<0.001, difference 4.7 (95% CI 2.3-7.0) and OPTION scores 36 vs. 25, p=0.001, difference 11.5 (95% CI 5.1-17.8), indicating greater information provision and behavior supporting patient involvement., Conclusion: Asking these three questions improved information given by family physicians and increased physician facilitation of patient involvement. Practice implications. These questions can drive evidence-based practice, strengthen patient-physician communication, and improve safety and quality., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objective: To examine the costs and cost-effectiveness of full implementation of biennial bowel cancer screening for Australian residents aged 50-74 years., Design and Setting: Identification of existing economic models from 1993 to 2010 through searches of PubMed and economic analysis databases, and by seeking expert advice; and additional modelling to determine the costs and cost-effectiveness of full implementation of biennial faecal occult blood test screening for the five million adults in Australia aged 50-74 years., Main Outcome Measures: Estimated number of deaths from bowel cancer prevented, costs, and cost-effectiveness (cost per life-year gained [LYG]) of biennial bowel cancer screening., Results: We identified six relevant economic analyses, all of which found colorectal cancer (CRC) screening to be very cost-effective, with costs per LYG under $55,000 per year in 2010 Australian dollars. Based on our additional modelling, we conservatively estimate that full implementation of biennial screening for people aged 50-74 years would have gross costs of $150 million, reduce CRC mortality by 15%-25%, prevent 300-500 deaths from bowel cancer, and save 3600-6000 life-years annually, for an undiscounted cost per LYG of $25,000-$41,667, compared with no screening, and not taking cost savings as a result of treatment into consideration. The additional expenditure required, after accounting for reductions in CRC incidence, savings in CRC treatment costs, and existing ad-hoc colonoscopy use, is likely to be less than $50 million annually., Conclusions: Full implementation of biennial faecal occult blood test screening in Australia can reduce bowel cancer mortality, and is an efficient use of health resources that would require modest additional government investment.

Objectives: (i) To document the current state of the English, Scottish, Welsh, Northern Irish and Australian bowel cancer screening programmes, according to seven key characteristics, and (ii) to explore the policy trade-offs resulting from inadequate funding., Setting: United Kingdom and Australia., Methods: A comparative case study design using document and key informant interview analysis. Data were collated for each national jurisdiction on seven key programme characteristics: screening frequency, population coverage, quality of test, programme model, quality of follow-up, quality of colonoscopy and quality of data collection. A list of optimal features for each of the seven characteristics was compiled, based on the FOBT screening literature and our detailed examination of each programme., Results: Each country made different implementation choices or trade-offs intended to conserve costs and/or manage limited and expensive resources. The overall outcome of these trade-offs was probable lower programme effectiveness as a result of compromises such as reduced screening frequency, restricted target age range, the use of less accurate tests, the deliberate setting of low programme positivity rates or increased inconvenience to participants from re-testing., Conclusions: Insufficient funding has forced programme administrators to make trade-offs that may undermine the potential net population benefits achieved in randomized controlled trials. Such policy compromise contravenes the principle of evidence-based practice which is dependent on adequate funding being made available.

Background: Between 2007 and 2009, Australian general practitioners (GPs) were involved in implementing a population-based human papillomavirus (HPV) vaccination program. We investigated GPs' experiences of delivering the HPV vaccine to women aged 18-26., Methods: We posted a survey to 1000 GPs. The survey was informed by 12 domains incorporating constructs from psychological theories that focus on individual and environmental barriers and facilitators to effective implementation of evidence-based practice by health professionals., Results: The response rate was 32%. The 298 vaccinating GPs were positive about HPV vaccine implementation as part of their professional role as a worthwhile initiative within existing general practice infrastructure. They had more negative views about some aspects of program organisation, such as the timelines and potential adverse impacts on cervical screening rates. Vaccine safety was not a key concern. Actual levels of knowledge about HPV were moderate (mean score 3.41 out of 6 (s.d. 0.99)) and contrasted with self-rated knowledge, which was high (93% perceived their knowledge to be adequate). Notably, there were unrealistic expectations about the likely reduction in Pap abnormalities due to vaccination, which is important to clarify to avoid loss of confidence in the vaccine when this reduction does not eventuate., Conclusions: Australian GPs viewed HPV vaccination of women aged 18-26 years as an integrated part of their routine practice, with positive attitudes regarding its benefits and achievability. GPs are well placed to implement mass immunisation programs as long as they are supported by effective and timely communication strategies and resources.

Objective: Previous studies have not assessed whether evidence-based information about the outcomes of colorectal cancer screening increases informed choice among people from a range of socioeconomic backgrounds nor have they assessed whether this can be administered away from a health-care provider., Methods: Randomized controlled trial in six primary care locations. Three hundred and fourteen people aged 50-74 years received a self-administered decision aid (DA) booklet about outcomes of biennial faecal occult blood testing (FOBT) screening or government consumer guidelines (G)., Results: Significantly more DA recipients (20.9%) were 'informed' compared with G recipients (5.8%) (P = 0.0001, OR 4.32; 95% CI 2.49 to 7.52); the DA did not affect values clarity (61.9% clear after DA versus 59.1% after G) nor screening decisions overall (87.3% would screen after DA versus 90.5% after G). Test uptake at one month was uniformly low (5.2% DA versus 6.6% G); mostly due to being 'too busy'. DA recipients were more likely to make decisions 'integrating' knowledge with values (10.4% DA versus 1.5% G). Decisions not to screen were equally uncommon in both groups but more likely to be uninformed in G (P = 0.03). More DA recipients from all education levels were 'informed' (P = 0.02), particularly in lower education (50.0% DA versus 17.8% G) and university-educated groups (79.4% DA versus 32.1% G)., Conclusion: Detailed absolute risk and benefit information about FOBT screening can be effectively used at home by people to increase informed choice. The DA was effective in people with lower education levels., Trial Registration: Unique Protocol ID 211705 ClinicalTrials.gov ID NCT 00148226.

Problem-based learning (PBL) has been implemented within numerous undergraduate health curricula but less so in workforce training. Public health practice requires many of the skills that PBL aims to develop such as teamwork, self-directed learning and the integration of multiple sources of information within problem solving. This paper summarises the historical development of PBL and the educational principles underpinning it. It hypothesises that the public health workforce would benefit from some exposure to this type of learning and highlights some of the practical issues for its implementation.

Adequate nutrition is an essential determinant of health. Disadvantaged individuals within the cities of developed countries continue to have poor health, yet the role of food insecurity in such groups is poorly understood. This cross-sectional study describes such experiences among 22 randomly selected participants who participated in interviews at a charity-run soup kitchen in urban Sydney, Australia. Interviews explored four constructs of food insecurity (quantitative, qualitative, psychological, and social), identifying related barriers and coping strategies. Reliable access to food was limited. Low income; high rents; poor health; and addictions to cigarettes, alcohol, illicit drugs, and gambling were associated with dependence on charities. Poor dentition and lack of food storage and cooking facilities were important barriers to adequate nutrition. Meals were missed and quantities restricted as a coping strategy. Participants demonstrated adequate knowledge and a desire to eat healthful food. Opportunities for social interaction and trust in soup kitchen staff were important motivators of attendance. Strategies to reduce food insecurity among seriously disadvantaged city dwellers should focus less on education and more on practical solutions, such as accessing affordable healthful food for those without kitchen facilities, improving dentition, and reducing addictions. It is also important to facilitate social networks with trusted support organizations.

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.

Objective: To determine whether an evidence based decision aid on the measles, mumps, and rubella (MMR) vaccine changed parents' attitudes towards vaccination., Design: Before and after study., Setting: Website promoted through search engines and online parenting and health websites., Participants: 158 people completing online questions out of 1277 who accessed the website., Intervention: Evidence based decision aid with text and graphical representation of the possible outcomes of measles, mumps, and rubella diseases compared with MMR vaccination., Main Outcome Measures: Attitudes towards MMR vaccination., Results: Significantly more participants indicated they were "leaning towards" vaccination after using the decision aid (39% before v 55% after, P < 0.001). Compared with those who were undecided or "leaning away from" vaccination after using the decision aid, participants "leaning towards" it were more likely to strongly value its potential to protect their children from the serious side effects of disease (98% v 84%) and other children who could not be vaccinated for medical reasons (68% v 25%). Participants with an unfavourable attitude to vaccination were more likely to be very concerned about the rare side effects of vaccination (78% v 57%), have residual concerns about autism and bowel disease (78% v 27%), and anticipate guilt should their child have an adverse reaction (77% v 50%). Those with a positive attitude to vaccination after using the decision aid were also more likely to feel well informed (83% v 48%)., Conclusions: A web based decision aid significantly improved parental attitudes to MMR vaccination. Residual concerns about autism and bowel disease and the rare chance of serious complications remained as attitudinal barriers to some parents.

Objectives: To identify perceptions of health, health concerns, and health service needs among young people in a suburb of Sydney, New South Wales., Design: Qualitative study using focus groups., Setting: Berowra, a geographically isolated suburb on the outskirts of Sydney, between December 2002 and April 2003., Participants: 40 Berowra residents aged 14-24 years, recruited from two local government high schools (two groups), a local youth drop-in centre (one group), and the community, through advertising at the youth centre, local schools and church groups (one group)., Results: Focus group findings were classified into four broad themes. 1: Personal safety is a primary health concern. Berowra needs more recreational facilities to prevent drug and alcohol use related to boredom. 2: Health is more about quality of life than disease and illness. 3: Most health information comes from sources other than health providers. Health education must enable young people to make wise choices for the future. 4: Access to health services is of concern. More education is required on how Medicare works. Young people need to trust their service provider and will only see a doctor if they perceive themselves to be severely ill. Young people value meeting general practitioners in the school and community setting and not just in the doctor's consulting room., Conclusions: Young people desire a whole lifestyle approach to health rather than the traditional model based on diagnosis and disease. Health information needs to be accessible anonymously, and healthy lifestyles need to be promoted throughout the whole community, using youth workers and sporting leaders as role models.

Objective: Whilst previous research has repeatedly documented premature mortality and high morbidity among seriously disadvantaged and homeless populations, far less is known of the extent and nature of their interactions with health services., Design and Setting: This cross-sectional case study describes health service utilization patterns and explores participant-reported difficulties in accessing health care, adhering to prescribed treatment and maintaining continuity of care amongst 100 users of a charity-run soup kitchen in urban Sydney. Participants and results. The study describes a largely welfare-dependent population sample with poor health who are frequent users of the health system (85% had seen a general practitioner in the preceding 6 months). The homeless were more likely to report difficulties accessing health care when needed [odds-ratio 3.15; 95% confidence interval (CI) 1.04-9.62]. One in three respondents reported difficulty adhering to prescribed treatment following their last health care visit. Affordability (P < 0.0001), not understanding instructions (P = 0.007), and not agreeing with advice (P < 0.0001) were the main factors associated with adherence difficulties. One in four failed to return for follow-up visits as advised, largely associated with attitudinal barriers such as a history of not believing problems would be addressed (P = 0.05), not trusting health professionals (P = 0.04), and not knowing where to get help in the past (P = 0.05)., Conclusion: These results reinforce the important role of free primary care in reducing access barriers for the disadvantaged, but also highlight possible reasons for service interactions being ineffective in a substantial proportion of cases.

Background: In this article, we describe the education model used to integrate population health learning into a new 4-year medical program at the University of Sydney., Method: Our two-pronged approach aims to prepare third-year students to integrate population health thinking into their day-to-day clinical reasoning and to equip them with skills to investigate specific population health topics. We provide an example of a student-led, small-group session on health issues for disadvantaged populations, along with an outline of our assessment and evaluation methods. This innovative course illustrates one approach to the challenge of motivating students to bridge the gap between their interest in the medical care of individual patients and the healthcare needs of whole populations., Results/conclusions: Students performed adequately in the assessments required for progression to the next year of the program. Students rated the case-based exercises; self-directed learning; on-line and library resources; tutor facilitation; and student-led, small-group sessions as effective methods for learning.

Objective: To assess the self-reported health status and its relationship to key demographic variables among patrons of a charity-run meals service at The Exodus Foundation, in urban Sydney, Australia., Method: Random-sample cross-sectional study of 100 face-to-face interviews (79% recruitment rate). Self-reported health status was measured by subjective rating scale, open-ended and checklist questions about presence and type of acute and chronic disease. Anaysis by logistic regression of fair-poor health status on demographic variables in Exodus patrons and genera Sydney population adjusted for age and sex using the 1995 National Health Survey., Results: Compared to housed but poor counterparts within the Exodus sample, homeless people were significantly more likely to report fair-poor health status (age-adjusted OR-3.0, 95% CI 1.3-7.1). Exodus patrons, as a whole, were much more likely than Sydney's general population to report fair-poor health status, after adjusting for age and sex (OR-4.5, 95% CI 2.9-7.0) and had a more serious pattern of illness (diseases of the digestive system; depression; common cold; bronchitis; refractive errors; drug and alcohol dependence; diabetes mellitus Type II). Exodus patrons reported fewer acute and chronic illnesses with open-ended questions than with a checklist (p<0.001)., Conclusion: In this population there was a strong relationship between poor health and homelessness. When patterns of illness and injury were measured within this disadvantaged group, they showed more serious illness types than in the general population. Such patterns may not be identified by methods often used in traditional population health surveys.