What do haematological cancer survivors want help with? A cross-sectional investigation of unmet supportive care needs

BACKGROUND: This study aimed to identify the most prevalent unmet needs of haematological cancer survivors. METHODS: Haematological cancer survivors aged 18–80 years at time of recruitment were selected from four Australian state cancer registries. Survivors completed the Survivor Unmet Needs Survey. The most frequently reported “high/very high” unmet needs items were identified, as well as characteristics associated with the three most prevalent “high/very high” unmet needs reported by haematological cancer survivors. RESULTS: A total of 715 eligible survivors returned a completed survey. “Dealing with feeling tired” (17%), was the most frequently endorsed “high/very high” unmet need. Seven out of the ten most frequently endorsed unmet needs related to emotional health. Higher levels of psychological distress (e.g., anxiety, depression and stress) and indicators of financial burden as a result of cancer (e.g., having used up savings and trouble meeting day-to-day expenses due to cancer) were consistently identified as characteristics associated with the three most prevalent “high/very high” unmet needs. CONCLUSIONS: A minority of haematological cancer survivors endorsed a “high/very high” unmet need on individual items. Additional emotional support may be needed by a minority of survivors. Survivors reporting high levels of psychological distress or those who experience increased financial burden as a result of their cancer diagnosis may be at risk of experiencing the most prevalent “high/very high” unmet needs identified by this study.This project was co-funded by beyondblue and Cancer Australia (Grant ID: 569290)

Interventions for improving medical students' interpersonal communication in medical consultations

Background Communication is a common element in all medical consultations, affecting a range of outcomes for doctors and patients. The increasing demand for medical students to be trained to communicate effectively has seen the emergence of interpersonal communication skills as core graduate competencies in medical training around the world. Medical schools have adopted a range of approaches to develop and evaluate these competencies. Objectives To assess the effects of interventions for medical students that aim to improve interpersonal communication in medical consultations. Search methods We searched five electronic databases: Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO, and ERIC (Educational Resource Information Centre) in September 2020, with no language, date, or publication status restrictions. We also screened reference lists of relevant articles and contacted authors of included studies. Selection criteria We included randomised controlled trials (RCTs), cluster‐RCTs (C‐RCTs), and non‐randomised controlled trials (quasi‐RCTs) evaluating the effectiveness of interventions delivered to students in undergraduate or graduate‐entry medical programmes. We included studies of interventions aiming to improve medical students’ interpersonal communication during medical consultations. Included interventions targeted communication skills associated with empathy, relationship building, gathering information, and explanation and planning, as well as specific communication tasks such as listening, appropriate structure, and question style. Data collection and analysis We used standard methodological procedures expected by Cochrane. Two review authors independently reviewed all search results, extracted data, assessed the risk of bias of included studies, and rated the quality of evidence using GRADE. Main results We found 91 publications relating to 76 separate studies (involving 10,124 students): 55 RCTs, 9 quasi‐RCTs, 7 C‐RCTs, and 5 quasi‐C‐RCTs. We performed meta‐analysis according to comparison and outcome. Among both effectiveness and comparative effectiveness analyses, we separated outcomes reporting on overall communication skills, empathy, rapport or relationship building, patient perceptions/satisfaction, information gathering, and explanation and planning. Overall communication skills and empathy were further divided as examiner‐ or simulated patient‐assessed. The overall quality of evidence ranged from moderate to very low, and there was high, unexplained heterogeneity. Overall, interventions had positive effects on most outcomes, but generally small effect sizes and evidence quality limit the conclusions that can be drawn. Communication skills interventions in comparison to usual curricula or control may improve both overall communication skills (standardised mean difference (SMD) 0.92, 95% confidence interval (CI) 0.53 to 1.31; 18 studies, 1356 participants; I² = 90%; low‐quality evidence) and empathy (SMD 0.64, 95% CI 0.23 to 1.05; 6 studies, 831 participants; I² = 86%; low‐quality evidence) when assessed by experts, but not by simulated patients. Students’ skills in information gathering probably also improve with educational intervention (SMD 1.07, 95% CI 0.61 to 1.54; 5 studies, 405 participants; I² = 78%; moderate‐quality evidence), but there may be little to no effect on students' rapport (SMD 0.18, 95% CI ‐0.15 to 0.51; 9 studies, 834 participants; I² = 81%; low‐quality evidence), and effects on information giving skills are uncertain (very low‐quality evidence). We are uncertain whether experiential interventions improve overall communication skills in comparison to didactic approaches (SMD 0.08, 95% CI ‐0.02 to 0.19; 4 studies, 1578 participants; I² = 4%; very low‐quality evidence). Electronic learning approaches may have little to no effect on students’ empathy scores (SMD ‐0.13, 95% CI ‐0.68 to 0.43; 3 studies, 421 participants; I² = 82%; low‐quality evidence) or on rapport (SMD 0.02, 95% CI ‐0.33 to 0.38; 3 studies, 176 participants; I² = 19%; moderate‐quality evidence) compared to face‐to‐face approaches. There may be small negative effects of electronic interventions on information giving skills (low‐quality evidence), and effects on information gathering skills are uncertain (very low‐quality evidence). Personalised/specific feedback probably improves overall communication skills to a small degree in comparison to generic or no feedback (SMD 0.58, 95% CI 0.29 to 0.87; 6 studies, 502 participants; I² = 56%; moderate‐quality evidence). There may be small positive effects of personalised feedback on empathy and information gathering skills (low quality), but effects on rapport are uncertain (very low quality), and we found no evidence on information giving skills. We are uncertain whether role‐play with simulated patients outperforms peer role‐play in improving students’ overall communication skills (SMD 0.17, 95% CI ‐0.33 to 0.67; 4 studies, 637 participants; I² = 87%; very low‐quality evidence). There may be little to no difference between effects of simulated patient and peer role‐play on students' empathy (low‐quality evidence) with no evidence on other outcomes for this comparison. Descriptive syntheses of results that could not be included in meta‐analyses across outcomes and comparisons were mixed, as were effects of different interventions and comparisons on specific communication skills assessed by the included trials. Quality of evidence was downgraded due to methodological limitations across several risk of bias domains, high unexplained heterogeneity, and imprecision of results. In general, results remain consistent in sensitivity analysis based on risk of bias and adjustment for clustering. No adverse effects were reported. Authors' conclusions This review represents a substantial body of evidence from which to draw, but further research is needed to strengthen the quality of the evidence base, to consider the long‐term effects of interventions on students’ behaviour as they progress through training and into practice, and to assess effects of interventions on patient outcomes. Efforts to standardise assessment and evaluation of interpersonal skills will strengthen future research efforts

An evidence-based approach to an evaluation of a health promoting schools intervention

Research Doctorate - Doctor of Philosophy (PhD)It is now widely accepted that schools are ideal settings for health promotion initiatives which target health and health risk behaviour of school-aged children. The current approach to school-based health promotion, known as the Health Promoting Schools (HPS) approach, embraces the principles of the Ottawa Charter and focuses on opportunities for action on: the formal school curriculum; the school environment (or informal curriculum); and links with the home and wider community. Acceptance and endorsement of the approach has come from several leading international and Australian health promotion organisations. Despite the large amount of interest and enthusiasm generated, there remain a number of significant gaps in knowledge and research evidence, particularly that which addresses the efficacy and effectiveness of the HPS approach. The recent drive by influential bodies for evidence-based heath promotion further supports the need for the application of a systematic framework to the development and evaluation of HPS interventions. This thesis, therefore, describes the application of the Staged Approach to health promotion practice and research model to the development and evaluation of a HPS intervention program which aims to reduce three priority health risk behaviours (smoking, unsafe alcohol use and inadequate sun protection) among a cohort sample of Australian adolescents. Chapter One of this thesis provides the background to the development of the HPS approach, identifies the key gaps in knowledge and research evidence, and outlines the stages of the Staged Approach model and its application to the development and evaluation of a HPS intervention. Chapter Two describes an audit of published literature over an 18-year period to provide an overall picture of the quantity of available evidence within each of the stages of health promotion practice. Chapter Three first identifies health issues which are appropriate to target in school-based health promotion, then applies Stages I and II of the Staged Approach by reviewing the available evidence on adequacy of measures and current prevalence, determinants and target groups. The design, methods and development of a measurement tool for a descriptive, baseline study on the prevalence and determinants of three health risk behaviours among young adolescents in the Hunter Region is outlined in Chapter Four, with the findings from this study described in Chapter Five. A critical review of school-based programs and HPS trials implemented to date is described in Chapter Six, as the first step in evaluating the efficacy and acceptability of interventions (Stage Ill of the Staged Approach). The review considers the extent to which the HPS approach has been conducted in trials, as well as issues regarding study design, outcomes and quality of available research. Chapter Seven describes a randomised controlled trial of a HPS intervention program which aimed to reduce the prevalence of three health risk behaviours among young adolescents in the Hunter region. The model of implementation and specific strategies are outlined, as well as the acceptability and degree of implementation as a process evaluation of the program. Chapter Eight reports on the impact/outcome evaluation of the program concerning its effectiveness in reducing the prevalence of three health risk behaviours and their determinants. Finally, Chapter Nine draws conclusions regarding the effectiveness of the HPS approach, provides recommendations for the implementation of future school-based health promotion initiatives and addresses issues of dissemination and wider adoption of HPS programs as indicated by the final stages of the Staged Approach model

What's good for the goose is good for the gander. Guiding principles for the use of financial incentives in health behaviour change

Background:The use of financial incentives or pay-for-performance programs for health care providers has triggered emerging interest in the use of financial incentives for encouraging health behaviour change. Purpose: This paper aims to identify key conditions under which the use of financial incentives for improvements in public health outcomes is most likely to be effective and appropriate. Methods: We review recent systematic reviews on their effectiveness in changing health behaviour and identify existing moral concerns concerning personal financial incentives. Results: Current evidence indicates that incentives can be effective in driving health behaviour change under certain provisos, while a number of misgivings continue to be deliberated on. We outline a number of key principles for consideration in decisions about the potential use of incentives in leading to public health improvements. Conclusion: These key principles can assist policy makers in making decisions on the use of financial incentives directed at achieving improvements in public health

Are Australian clinicians monitoring medication adherence in hematological cancer survivors?:Two cross-sectional studies

Background: Hematological cancer survivors are growing in number and increasingly rely on oral therapy. Given known poor outcomes associated with non-adherence and previous evidence that many patients do not fully adhere to their treatment regimen, this study aimed to determine the degree to which clinicians monitor adherence to oral medication in hematological cancer survivors. Methods: Data was combined from two cross-sectional surveys of a heterogeneous sample of 431 hematological cancer survivors recruited from three outpatient hematology clinics in three different states (n=215) and one state cancer registry (n=216) in Australia. Participants completed a self-administered survey that included demographic characteristics and a 7-item measure of medication adherence developed by the researchers specifically for the purpose of the studies. Results: Of the 431 participants, 37% (n=160) reported currently taking daily cancer-related medication. Of these, 14% (n=23) were found to be non-adherent with 'missing a dose' being the most commonly reported non-adherent behaviour. Only 41% of survivors indicated that their hematologist or cancer clinician had 'always' asked about their cancer-related medication during their last six visits. Conclusion: Non-adherence to oral therapy remains a problem in hematological cancer survivors, yet clinicians in Australia do not appear to be regularly monitoring adherence in their patients. Given an increasing dependence on oral therapy in clinical hematology and medical oncology and the importance of medication adherence to optimising health outcomes, greater effort should be invested in developing effective interventions to improve support and adherence monitoring by cancer clinicians and GPs

Factors associated with haematological cancer survivors experiencing a high level of unmet need across multiple items of supportive care: a cross-sectional survey study

Purpose: This study aimed to identify subgroups of haematological cancer survivors who report a “high/very high” level of unmet need on multiple (≥7) items of supportive care.Results: Of the 696 survivors included in this study, 175 (n = 25 %) rep

Format and readability of an enhanced invitation letter did not affect participation rates in a cancer registry-based study: a randomized controlled trial

Objectives: To assess the effectiveness of an “enhanced” invitation letter in increasing participation in an Australian cancer registry-based study and assess the representativeness of the study sample. Study Design and Setting: Eight hundred hematological cancer survivors, diagnosed within the last 3 years and aged 18–80 years at recruitment, were selected from one Australian state-based cancer registry. Half were randomly allocated to receive the standard invitation letter (control group). The remaining half received a modified invitation letter, incorporating content and design characteristics recommended to improve written communication (intervention group). Results: Of the 732 eligible survivors, 268 (37%) returned a completed survey. There was no difference in participation between the intervention (n = 131, 36%) and control groups (n = 137, 38%; P = 0.53). Participants were representative of the population for characteristics assessed, except for age group at diagnosis. Survivors 50 years or older at diagnosis had higher odds of returning a completed survey, 50–59 (odds ratio [OR]: 2.53; 95% confidence interval [CI]: 1.47, 4.35), 60–69 (OR: 2.69; 95% CI: 1.58–4.58), and 70–80 (OR: 1.90; 95% CI: 1.07–3.35), than survivors aged 15–39 years at diagnosis. Conclusion: An enhanced invitation letter was not effective in increasing participation of hematological cancer survivors in an Australian cancer registry study. The study sample was moderately representative on variables assessed, with age group at diagnosis the only variable associated with participation. Research should evaluate strategies to increase participation in registry studies and focus on tailoring techniques to patient's age