Palliative care interventional research in general practice: a narrative review of factors affecting research conduct.

BACKGROUND AND OBJECTIVE: The majority of palliative care provision occurs in general practice, yet only 9% of palliative care clinical trials were conducted in this setting. Evidence from hospital and specialist settings is not readily transferable to general practice, as the population, context and care processes are vastly different. Conducting interventional palliative care research in general practice settings is subject to many challenges and barriers. This narrative review aims to describe the factors influencing the conduct of interventional research in general practice settings for patients with palliative care needs. METHODS: A narrative review was performed to identify factors affecting the conduct of palliative care interventional studies in general practice. A literature search of MEDLINE was conducted on 26 September 2023, and data were synthesised utilising a narrative approach. KEY CONTENT AND FINDINGS: Sixteen articles were identified. Five thematic groupings were identified from the literature that affected the interventions: factors related to health care professionals (HCPs), patients and carers, general practices, health systems, and research design. HCPs and practices were focused on providing clinical care and struggled to incorporate research into their workload. Staff and patients often had negative perceptions in palliative care combined with limited research experience, often resulting in unwillingness to engage in interventions and gatekeeping. Engaging with general practice staff to design, participate and champion research were key facilitators of successful interventions. CONCLUSIONS: Palliative care interventions in general practice are invariably complex and challenging, yet acutely needed to address the care needs of patients in the community setting. Working together with patients, carers and clinicians to design and implement interventions appropriate for general practice settings is fundamental to their success.

"We need to work towards it, whatever it takes."-participation factors in the acceptability and feasibility of lung cancer screening in Australia: the perspectives of key stakeholders.

Background: Low dose computed tomography (LDCT) screening, targeted at those at high-risk, has been shown to significantly reduce lung cancer mortality and detect cancers at an early stage. Practical, attitudinal and demographic factors can inhibit screening participation in high-risk populations. This study aimed to explore stakeholders' views about barriers and enablers (determinants) to participation in lung cancer screening (LCS) in Australia. Methods: Twenty-four focus groups (range 2-5 participants) were conducted in 2021 using the Zoom platform. Participants were 84 health professionals, researchers, policy makers and program managers of current screening programs. Focus groups consisted of a structured presentation with facilitated discussion lasting about 1 hour. The content was analysed thematically and mapped to the Consolidated Framework for Implementation Research (CFIR). Results: Screening determinants were identified across each stage of the proposed screening and assessment pathway. Challenges included participant factors such as encouraging participation for individuals at high-risk, whilst ensuring that access and equity issues were carefully considered in program design. The development of awareness campaigns that engaged LCS participants and health professionals, as well as streamlined referral processes for initial entry and follow-up, were strongly advocated for. Considering practical factors included the use of mobile vans in convenient locations. Conclusions: Participants reported that LCS in Australia was acceptable and feasible. Participants identified a complex set of determinants across the proposed screening and assessment pathway. Strategies that enable the best chance for program success must be identified prior to implementation of a national LCS program.

Improving feedback literacy in a primary care rotation.

Primary care education is a unique clinical experience for medical students. It is community-based and provides an opportunity for students to learn consultation skills with multiple sources of workplace-based feedback. Meaningful and demonstrable utilisation of this feedback by students remains an educational challenge. We showcase achievable changes to educational tasks in an established curriculum, which aim to improve student feedback literacy and create a feedback loop which improves on previous provision of unidirectional, terminal feedback. The changes have been well-received, with student and educator engagement being positive. Students have demonstrated critical reflection on feedback, and development in consultation and clinical reasoning skills.

Feasibility and acceptability of facilitated advance care planning in outpatient clinics: A qualitative study of health-care professionals experience.

OBJECTIVE: This study sought to determine the feasibility and acceptability of a facilitated advance care planning (ACP) intervention implemented in outpatient clinics, as perceived by health-care professionals (HCPs). METHODS: Data from seven focus groups (n = 27) and nine semi-structured interviews with HCPs recruited as part of a pragmatic, randomised controlled trial (RCT) were analysed using qualitative descriptive methodology. Components of the intervention included HCP education and training, tools to assist HCPs with patient selection, hardcopy information, and ACP documentation, and specialised nurse-facilitators to support HCPs to complete ACP conversations and documentation with patients and caregivers. RESULTS: Health-care professionals working in tertiary outpatient clinics perceived the facilitated ACP intervention as feasible and acceptable. Health-care professionals reported a high level of satisfaction with key elements of the intervention, including the specialised education and training, screening and assessment procedures and ongoing support from the nurse-facilitators. Health-care professionals reported this training and support increased their confidence and ACP knowledge, leading to more frequent ACP discussions with patients and their families. Health-care professionals noted their ability to conduct ACP screening and assessment in clinic was impeded by large clinical caseloads and patient-related factors (e.g., dementia diagnoses, and emotional distress). Additional barriers to ACP implementation identified by HCPs included poor collaboration, constrained time and clinical space, undefined roles and standardised recording procedures for HCPs. CONCLUSIONS: Facilitated ACP intervention in outpatient clinics is perceived by HCPs as feasible and acceptable. Addressing barriers and tailoring implementation strategies may improve the delivery of ACP as part of tertiary outpatient care.

Impact of multimorbidity and complex multimorbidity on healthcare utilisation in older Australian adults aged 45 years or more: a large population-based cross-sectional data linkage study.

OBJECTIVES: As life expectancy increases, older people are living longer with multimorbidity (MM, co-occurrence of ≥2 chronic health conditions) and complex multimorbidity (CMM, ≥3 chronic conditions affecting ≥3 different body systems). We assessed the impacts of MM and CMM on healthcare service use in Australia, as little was known about this. DESIGN: Population-based cross-sectional data linkage study. SETTING: New South Wales, Australia. PARTICIPANTS: 248 496 people aged ≥45 years who completed the Sax Institute's 45 and Up Study baseline questionnaire. PRIMARY OUTCOME: High average annual healthcare service use (≥2 hospital admissions, ≥11 general practice visits and ≥2 emergency department (ED) visits) during the 3-year baseline period (year before, year of and year after recruitment). METHODS: Baseline questionnaire data were linked with hospital, Medicare claims and ED datasets. Poisson regression models were used to estimate adjusted and unadjusted prevalence ratios for high service use with 95% CIs. Using a count of chronic conditions (disease count) as an alternative morbidity metric was requested during peer review. RESULTS: Prevalence of MM and CMM was 43.8% and 15.5%, respectively, and prevalence increased with age. Across three healthcare settings, MM was associated with a 2.02-fold to 2.26-fold, and CMM was associated with a 1.83-fold to 2.08-fold, increased risk of high service use. The association was higher in the youngest group (45-59 years) versus the oldest group (≥75 years), which was confirmed when disease count was used as the morbidity metric in sensitivity analysis.When comparing impact using three categories with no overlap (no MM/CMM, MM with no CMM, and CMM), CMM had greater impact than MM across all settings. CONCLUSION: Increased healthcare service use among older adults with MM and CMM impacts on the demand for primary care and hospital services. Which of MM or CMM has greater impact on risk of high healthcare service use depends on the analytic method used. Ageing populations living longer with increasing burdens of MM and CMM will require increased Medicare funding and provision of integrated care across the healthcare system to meet their complex needs.

Strategies to Improve Statin Medication Adherence Among Patients at Risk of Cardiovascular Disease Identified Through Electronic Health Records: A Literature Review.

Statin is a group of lipid/cholesterol-lowering medications that is commonly used for primary and secondary prevention of cardiovascular diseases (CVD). In Australia, this is the first line of pharmacological therapy for CVD risk management. High-risk patients who do not adhere to lipid-modifying medicines have an increased risk of CVD mortality, hospitalization, and revascularization. However, studies show that 67% of patients are non-adherent to statins. As such, improving statin adherence through various strategies is very important. This literature review delves into the studies from the past 10 years to identify the various strategies used and their effectiveness to improve statin adherence. The initial search results on PubMed showed 157 articles and based on the inclusion and exclusion criteria, 7 articles were finally used for this review. The patients in the studies were identified through electronic health records. The findings suggest that education, counselling and motivation through face-to-face interaction, phone calls or text messages, reminder messages and frequent follow-up visits are good strategies to improve statin adherence. Alongside these, simplifying regimens, switching combinations of medicines, or using alternate dosing have also been shown to improve statin adherence. In summary, counselling and face-to-face interaction are effective methods for improving statin adherence. The use of electronic health record (EHR) systems combined with targeted interventions delivered to patients identified to be non-adherent to statin may further improve statin adherence.

Feasibility and Acceptability of Facilitated Advance Care Planning in Outpatient Clinics: A Qualitative Study of Patient and Caregivers Experiences.

Guidelines recommend advance care planning (ACP) for people with advanced illness; however, evidence supporting ACP as a component of outpatient care is lacking. We sought to establish the feasibility and acceptability of a facilitated ACP intervention for people attending tertiary outpatient clinics. Data from 20 semi-structured interviews with patient (M = 79.3 ± 7.7, 60% male) and caregiver (M = 68.1 ± 11.0, 60% female) participants recruited as part of a pragmatic, randomized controlled trial (RCT) were analyzed using qualitative descriptive methodology. Patients were randomized to intervention (e.g., facilitated support) or control (e.g., standard care). Intervention patients expressed high satisfaction, reporting the facilitated ACP session was clear, straightforward, and suited to their needs. Intervention caregivers did not report any significant concerns with the facilitated ACP process. Control participants reported greater difficulty completing ACP compared to intervention participants. Embedding facilitated ACP into tertiary outpatient care appears feasible and acceptable for people with advanced illnesses.

Alcohol consumption and health-related quality of life in regional, rural and metropolitan Australia: analysis of cross-sectional data from the Community Health and Rural/Regional Medicine (CHARM) study.

BACKGROUND: Relationships between alcohol consumption and health are complex and vary between countries, regions, and genders. Previous research in Australia has focused on estimating the effect of alcohol consumption on mortality. However, little is known about the relationships between alcohol consumption and health-related quality of life (QoL) in Australia. This study aimed to investigate the levels of alcohol intake and QoL in males and females in rural, regional and metropolitan areas of Australia. METHOD: Participants (n = 1717 Australian adults) completed an online cross-sectional study. Males and females were compared on measures including the AUDIT-C and WHOQOL-BREF. Data were stratified into risk of alcohol use disorder (AUD) and associations were examined between alcohol consumption and QoL, adjusting for sociodemographic variables. RESULTS: Males had higher alcohol consumption and were at greater risk of AUD than females (20% vs 8%). Relationships between alcohol consumption and QoL were positive or non-significant for low-moderate AUD risk categories and negative in the severe AUD risk category. Males in regional communities reported higher alcohol consumption (AUDIT-C score 6.6 vs 4.1, p < 0.01) than metropolitan areas. Regression analyses identified that after adjusting for sociodemographic variables, alcohol consumption was positively related to overall, environmental, and physical QoL and general health. CONCLUSION: The results indicate that alcohol consumption is negatively related to QoL only in those with severe risk of AUD. Males in regional areas reported higher alcohol consumption than those in metropolitan areas. These results provide further information about relationships between alcohol intake and health in Australia that can help inform prevention, screening and delivery of interventions.

CHIME-GP trial of online education for prescribing, pathology and imaging ordering in general practice - how did it bring about behaviour change?

BACKGROUND: There is a need for scalable clinician education in rational medication prescribing and rational ordering of pathology and imaging to help improve patient safety and enable more efficient utilisation of healthcare resources. Our wider study evaluated the effectiveness of a multifaceted education intervention for general practitioners (GPs) in rational prescribing and ordering of pathology and imaging tests, in the context of Australia's online patient-controlled health record system, My Health Record (MHR), and found evidence for measurable behaviour change in pathology ordering among participants who completed the educational activities. This current study explored the mechanisms of behaviour change brought about by the intervention, with a view to informing the development of similar interventions in the future. METHODS: This mixed methods investigation used self-reported questionnaires at baseline and post-education on MHR use and rational prescribing and test ordering. These were analysed using multi-level ordinal logistic regression models. Semi-structured interviews pre- and post-intervention were also conducted and were analysed thematically using the COM-B framework. RESULTS: Of the 106 GPs recruited into the study, 60 completed baseline and 37 completed post-education questionnaires. Nineteen participants were interviewed at baseline and completion. Analysis of questionnaires demonstrated a significant increase in confidence using MHR and in self-reported frequency of MHR use, post-education compared with baseline. There were also similar improvements in confidence across the cohort pre-post education in deprescribing, frequency of review of pathology ordering regimens and evidence-based imaging. The qualitative findings showed an increase in GPs' perceived capability with, and the use of MHR, at post-education compared with baseline. Participants saw the education as an opportunity for learning, for reinforcing what they already knew, and for motivating change of behaviour in increasing their utilisation of MHR, and ordering fewer unnecessary tests and prescriptions. CONCLUSIONS: Our education intervention appeared to provide its effects through providing opportunity, increasing capability and enhancing motivation to increase MHR knowledge and usage, as well as rational prescribing and test ordering behaviour. There were overlapping effects of skills acquisition and confidence across intervention arms, which may have contributed to wider changes in behaviour than the specific topic area addressed in the education. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN12620000010998) (09/01/2020).

Randomised trial of general practitioner online education for prescribing and test ordering.

INTRODUCTION: Potentially inappropriate medicine prescriptions and low-value diagnostic testing pose risks to patient safety and increases in health system costs. The aim of the Clinical and Healthcare Improvement through My Health Record usage and Education in General Practice study was to evaluate a scalable online quality improvement intervention, integrating online education regarding a national shared electronic health record and rational prescribing, pathology and imaging ordering by Australian general practitioners (GPs). METHODS: The study was a parallel three-arm randomised trial comprising a prescribing education arm, a pathology education arm and an imaging education arm. Currently practising GPs in Australia were eligible to participate and randomised on a 1:1:1 basis to the study arms after consenting. The response to the intervention in reducing potentially unnecessary medicine prescriptions and tests in each arm was assessed using the other two arms as controls. The primary outcome was the cost per 100 consultations of predefined medication prescriptions, pathology and radiology test ordering 6 months following the intervention, compared with 6 months prior. Outcomes were assessed on intention-to-treat and post hoc per-protocol bases using multilevel regression models, with the analysts blinded to allocation. RESULTS: In total, 106 GPs were enrolled and randomised (prescribing n=35, pathology n=36, imaging n=35). Data were available for 97 GPs at the end of trial (prescribing n=33, pathology n=32, imaging n=32) with 44 fully completing the intervention. In intention-to-treat analysis, there were no significant differences in the rates of change in costs across the three arms. Per protocol, there was a statistically significant difference in the rate of change in pathology costs (p=0.03). In the pathology arm, the rate of increase in pathology costs was significantly lower by $A187 (95% CI -$A340, -$A33) than the prescribing arm, and non-significantly $A9 (95% CI -$A128, $A110) lower than the imaging arm. DISCUSSION: This study provides some evidence for reductions in costs for low-value pathology test ordering in those that completed the relevant online education. The study experienced slow uptake and low completion of the education intervention during the COVID-19 pandemic. Changes were not significant for the primary endpoint, which included all participants. Improving completion rates and combining real-time feedback on prescribing or test ordering may increase the overall effectiveness of the intervention. Given the purely online delivery of the education, there is scope for upscaling the intervention, which may provide cost-effectiveness benefits. TRIAL REGISTRATION NUMBER: ACTRN12620000010998.

Demystifying human research ethics committee applications.

BACKGROUND: The National Health and Medical Research Council's National Statement on Ethical Conduct in Human Research and updated Guidelines for Ethical Conduct in Aboriginal and Torres Strait Islander Health Research provide guidance for primary care researchers. OBJECTIVE: This paper describes a step-by-step approach to ethics applications for research projects in primary care for new or inexperienced researchers, or those new to primary care research. DISCUSSION: Domains that may enhance ethics applications include increased consumer involvement; comprehensive literature reviews; evidence of researcher training in ethical research and clinical trials; the use of online platforms for participant information, consent processes and surveys; and consideration of the risks of genomic research or research in subpopulations. This paper discusses steps required when preparing ethics applications to ensure the community, clinicians and researchers are protected.

Attitudes and Perceptions on Advance Care Planning Among Chinese-Speaking Older Australians.

BACKGROUND: Current literature indicates low uptake of advance care planning (ACP) among the Chinese-speaking community in Australia. To increase the uptake of ACP among the Chinese-speaking community, a better understanding of their attitudes and perceptions on end-of-life (EOL) matters, and ACP is required. OBJECTIVE: This study aimed to identify significant events and social and cultural factors that influence participants' values and characterize the attitudes and perceptions towards ACP among older Chinese-speaking Australians. METHODS: A qualitative study explored participants' experiences through semi-structured one-to-one interviews. The interviews were conducted in Mandarin, Cantonese or English, then translated and transcribed into English. The transcripts were coded and analysed thematically. RESULTS: Twenty participants were recruited (14 female, six male). Participants typically reported a preference to make health-related decisions autonomously. Their perspectives were grounded in past experiences of illnesses and EOL decision-making of loved ones, personal values, and perceived needs. Family dynamics and intimacy of relationships appeared to influence the role and responsibility of family members in EOL decision-making and ACP. Most participants perceived the need to engage in ACP only when encountering significant health changes or higher care needs. CONCLUSION: Healthcare professionals should initiate ACP discussion using culturally appropriate communication with consideration of personal values, past experiences and family dynamics. Efforts should be invested in raising public awareness of ACP within the Chinese-Australian community.

Exploring patients' advance care planning needs during the annual 75+ health assessment: survey of Australian GPs' views and current practice.

BACKGROUND: The 75+ health assessment has been identified as a suitable trigger to introduce advance care planning (ACP) to general practice patients. Australian general practitioners (GPs) were surveyed to explore their perceptions, attitudes and practices in introducing ACP during 75+ health assessments. METHODS: A cross-sectional postal survey of Australian GPs covering their personal, professional and workplace characteristics, their current practice regarding ACP within a 75+ health assessment, and their attitude towards ACP. Multivariate logistic regression was used to analyse the factors associated with routinely discussing ACP as part of the 75+ health assessment. RESULTS: A total of 185 (19.2%) out of 964 eligible GPs returned a completed survey. Most GPs reported that patients interested in ACP were supported by the GPs or the practice nurse. Two factors, (1) attitude that ACP is an essential component of the 75+ health assessment, and (2) regional or rural location of the practice, had a statistically and clinically significant association with the GP's self-reported discussion of ACP during 75+ health assessments. CONCLUSIONS: GPs showed a high level of support and involvement in discussing ACP during 75+ health assessments. ACP support during 75+ health assessments was often provided directly by the GP or via the practice nurse. Given the international evidence that ACP training programs improve skills and knowledge, and foster positive attitudes towards ACP, there is an important need to continue funding ACP training programs for GPs and practice nurses.

Does Geography Play a Role in the Receipt of End-of-Life Care for Advanced Cancer Patients? Evidence from an Australian Local Health District Population-Based Study.

Objectives: To assess the influence of geographic remoteness on health care utilization at end of life (EOL) by people with advanced cancer in a geographically diverse Australian local health district, using two objective measures of rurality and travel-time estimations to health care facilities. Methods: This retrospective cohort study examined the association between rurality (using the Modified Monash Model) and travel-time estimation, and demographic and clinical factors, with the receipt of >1 inpatient and outpatient health service in the last year of life in multivariate models. The study cohort comprised of 3546 patients with cancer, aged ≥18 years, who died in a public hospital between 2015 and 2019. Results: Compared with decedents from metropolitan areas, decedents from some rural areas had higher rates of emergency department visits (small rural towns: aRR 1.29, 95% CI: 1.07-1.57) and ICU admissions (large rural towns: aRR 1.32, 95% CI: 1.03-1.69), but lower rates of acute hospital admissions (large rural towns: aRR 0.83, 95% CI: 0.76-0.90), inpatient palliative care (PC) (regional centers: aRR 0.85, 95% CI: 0.75-0.97), and inpatient radiotherapy (lowest in small rural towns: aRR 0.07, 95% CI: 0.03-0.18). Decedents from rural and regional centers had lower rates of outpatient chemotherapy and radiotherapy use, yet higher rates of outpatient cancer service utilization (p < 0.05). Shorter travel times (10-<30 minutes) were associated with higher rates of inpatient specialist PC (aRR 1.48, 95% CI: 1.09-1.98). Conclusions: Reporting on a series of inpatient and outpatient services used in the last year of life, measures of rurality and travel-time estimates can be useful tools to estimate geographic variation in EOL cancer care provision, with significant gaps uncovered in inpatient PC and outpatient service utilization in rural areas. Policies aimed at redistributing EOL resources in rural and regional communities to reduce travel times to health care facilities could help to reduce regional disparities and ensure equitable access to EOL care services.

Challenges and strategies to improve the provision of end-of-life cancer care in rural and regional communities: Perspectives from Australian rural health professionals.

OBJECTIVE: To identify challenges and strategies to improve the provision of end-of-life (EOL) cancer care in an underserved rural and regional Australian local health district (LHD) from the perspective of general practitioners (GPs) and specialist clinicians while exploring the benefits of adopting a generalist health care approach to delivering EOL care in rural and regional communities. SETTING: Rural and regional Australia. PARTICIPANTS: General practitioners and palliative care and cancer care specialists (medical and nursing) involved in the provision of EOL care to people with advanced cancer in the rural and regional areas of an Australian LHD. DESIGN: Qualitative descriptive study involving 22 participants in four face-to-face and online focus groups. Thematic analysis of the transcripts identified key issues affecting EOL care for people with advanced cancer in rural and regional areas of the LHD. RESULTS: Four themes including geographical remoteness, system structures, medical management and expertise and training emerged from the focus groups. Key barriers to effective EOL care included insufficient remuneration for GPs and other clinicians (especially home visits), resource limitations, limited community awareness of palliative care and lack of confidence and training of clinicians. Continuity of care was identified as an important facilitator to effective EOL care. Participants suggested greater Medicare rebates for palliative care and home visits, adequate equipment and resources, technology-enabled clinician training and greater rural-based training for specialist PC clinicians may improve the provision of EOL care in regional and rural communities. CONCLUSIONS: Rural-based clinicians delivering EOL cancer care appear to be disproportionately affected by geographical challenges including resource and funding limitations. A multi-pronged strategy aimed at greater interdisciplinary collaboration, community awareness and greater resourcing and funding could help to improve the provision of EOL care in underserved rural and remote communities of Australia.

"What do I think about implementing lung cancer screening? It all depends on how." Acceptability and feasibility of lung cancer screening in Australia: The view of key stakeholders about health system factors.

BACKGROUND: Lung cancer is the number one cause of cancer death worldwide. Although international trials demonstrate that targeted screening using low dose computed tomography (LDCT) significantly reduces lung cancer mortality, implementation of screening in the high-risk population presents complex health system challenges that need to be thoroughly understood to support policy change. AIM: To elicit health care providers' and policymakers' views about the acceptability and feasibility of lung cancer screening (LCS) and barriers and enablers to implementation in the Australian setting. METHODS: We conducted 24 focus groups and three interviews (22 focus groups and all interviews online) in 2021 with 84 health professionals, researchers, and current cancer screening program managers and policy makers across all Australian states and territories. Focus groups included a structured presentation about lung cancer and screening and lasted approximately one hour each. A qualitative approach to analysis was used to map topics to the Consolidated Framework for Implementation Research. RESULTS: Nearly all participants considered LCS to be acceptable and feasible but identified a wide range of implementation challenges. Topics (five specific to health systems and five cross-cutting with participant factors) identified were mapped to CFIR constructs, of which 'readiness for implementation', 'planning' and 'executing' were most salient. Health system factor topics included delivery of the LCS program, cost, workforce considerations, quality assurance and complexity of health systems. Participants strongly advocated for streamlined referral processes. Practical strategies to address equity and access, such as using mobile screening vans, were emphasised. CONCLUSIONS: Key stakeholders readily identified the complex challenges associated with the acceptability and feasibility of LCS in Australia. The barriers and facilitators across health system and cross-cutting topics were clearly elicited. These findings are highly relevant to the scoping of a national LCS program by the Australian Government and a subsequent recommendation for implementation.

Initiating advance care planning in New South Wales general practices using a structured conversation guide

METHOD: Three focus groups were held as part of an existing initiative, 'Ask, Share, Know: Rapid Evidence for General Practice Decisions'. Data were analysed using an inductive thematic approach; themes identified informed adaptation of the conversation guide. RESULTS: Five key themes were identified: 1. general practice provides the optimal context for ACP discussions; 2. ACP priorities differ between GPs; 3. healthcare professionals' roles in ACP vary; 4. confusion exists regarding ACP practice; and 5. the adapted conversation guide provides a useful structure for ACP. DISCUSSION: ACP practice varies between GPs. GPs preferred the adapted conversation guide, but further evaluation is required prior to implementation into practice.

Motivation is not enough: A qualitative study of lung cancer screening uptake in Australia to inform future implementation.

INTRODUCTION: Participation in lung cancer screening (LCS) trials and real-world programs is low, with many people at high-risk for lung cancer opting out of baseline screening after registering interest. We aimed to identify the potential drivers of participation in LCS in the Australian setting, to inform future implementation. METHODS: Semi-structured telephone interviews were conducted with individuals at high-risk of lung cancer who were eligible for screening and who had either participated ('screeners') or declined to participate ('decliners') in the International Lung Screening Trial from two Australian sites. Interview guide development was informed by the Precaution Adoption Process Model. Interviews were audio-recorded, transcribed and analysed using the COM-B model of behaviour to explore capability, opportunity and motivation related to screening behaviour. RESULTS: Thirty-nine participants were interviewed (25 screeners; 14 decliners). Motivation to participate in screening was high in both groups driven by the lived experience of lung cancer and a belief that screening is valuable, however decliners unlike their screening counterparts reported low self-efficacy. Decliners in our study reported challenges in capability including ability to attend and in knowledge and understanding. Decliners also reported challenges related to physical and social opportunity, in particular location as a barrier and lack of family support to attend screening. CONCLUSION: Our findings suggest that motivation alone may not be sufficient to change behaviour related to screening participation, unless capability and opportunity are also considered. Focusing strategies on barriers related to capability and opportunity such as online/telephone support, mobile screening programs and financial assistance for screeners may better enhance screening participation. Providing funding for clinicians to support individuals in decision-making and belief in self-efficacy may foster motivation. Targeting interventions that connect eligible individuals with the LCS program will be crucial for successful implementation.

Factors influencing early presentation to general practitioners for non-screen detected breast cancer.

BACKGROUND AND OBJECTIVES: Women living in rural Australia have worse survival rates for breast cancer compared with their urban counterparts. Identifying factors that contribute to delayed presentation could help to reduce this disparity. This study aimed to identify and explore the differences in help-seeking behaviours between rural and urban women with non-screen-detected breast cancer. METHOD: We conducted a qualitative study consisting of semi-structured interviews with 20 women from New South Wales with non-screen detected breast cancer that was diagnosed within the past five years. RESULTS: There was little difference between rural and urban groups in terms of symptom appraisal and monitoring, social interactions, and personal and environmental factors. However, the presence of stoicism as a barrier was unique to rural women. Rural women also faced significant barriers in accessing general practice services that pertained to availability, cost and distance. DISCUSSION: GPs play a critical role in facilitating earlier presentation, and more research into rural stoicism is required. Continued investment in the rural primary care workforce will be key to improving access issues.