Short Research Article: Changes in life functioning in a self-help, online program for child and adolescent anxiety.

BACKGROUND: Anxiety-related functional impairment, as reflected by life interference, is a lesser explored but highly relevant treatment outcome, and it is crucial that it be included and examined in the evaluation of treatment outcomes of internet-delivered Cognitive Behavioural Therapy (iCBT). METHODS: This single group, pre-post study examined changes in life interference and anxiety symptoms in a sample of children (n = 1198; mean age 9.66 years) and adolescents (n = 721; mean age 13.66 years) participating in the BRAVE Self-Help program in Australia. RESULTS: Results demonstrated that both children and adolescents showed improvements in anxiety symptoms, with effect sizes ranging from ηp 2  = .194-.318. Reductions in life interference were evident for children (ηp 2  = .008-.044), particularly later in the programme, but adolescents did not show such effects. Adolescents in the low completer group (completing 3-5 sessions) showed increases in at-home interference (ηp 2  = .038). CONCLUSIONS: Adolescents in particular may require more sessions before entrenched life interference, such as that resulting from avoidance behaviours, can be overcome.

Mental health symptoms in children and adolescents during COVID-19 in Australia.

OBJECTIVE: COVID-19 has led to disruptions to the lives of Australian families through social distancing, school closures, a temporary move to home-based online learning, and effective lockdown. Understanding the effects on child and adolescent mental health is important to inform policies to support communities as they continue to face the pandemic and future crises. This paper sought to report on mental health symptoms in Australian children and adolescents during the initial stages of the pandemic (May to November 2020) and to examine their association with child/family characteristics and exposure to the broad COVID-19 environment. METHODS: An online baseline survey was completed by 1327 parents and carers of Australian children aged 4 to 17 years. Parents/carers reported on their child's mental health using five measures, including emotional symptoms, conduct problems, hyperactivity/inattention, anxiety symptoms and depressive symptoms. Child/family characteristics and COVID-related variables were measured. RESULTS: Overall, 30.5%, 26.3% and 9.5% of our sample scored in the high to very high range for emotional symptoms, conduct problems and hyperactivity/inattention, respectively. Similarly, 20.2% and 20.4% of our sample scored in the clinical range for anxiety symptoms and depressive symptoms, respectively. A child's pre-existing mental health diagnosis, neurodevelopmental condition and chronic illness significantly predicted parent-reported child and adolescent mental health symptoms. Parental mental health symptoms, having a close contact with COVID-19 and applying for government financial assistance during COVID-19, were significantly associated with child and adolescent mental health symptoms. CONCLUSION: Our findings show that Australian children and adolescents experienced considerable levels of mental health symptoms during the initial phase of COVID-19. This highlights the need for targeted and effective support for affected youth, particularly for those with pre-existing vulnerabilities.

Survivorship care plans and information for rural cancer survivors.

PURPOSE: The purpose of the study was to investigate the amount and type of survivorship care information received by cancer survivors living in rural Australia and whether this varies according to demographic factors or cancer type. METHODS: Self-reported receipt of a survivorship care plan (SCP) and information on various aspects of survivorship care (e.g., managing side effects, healthy lifestyles, psychosocial advice and monitoring for recurrence) were collected from 215 cancer survivors who had returned home to a rural area in Queensland Australia after receiving cancer treatment in a major city within the previous 5 years (72% in the previous 12 months). Logistic regression was used to assess for differences across demographic factors and cancer type. RESULTS: Only 35% of participants reported receiving a SCP and proportions of those reporting the receipt of specific information varied from 74% for information on short-term side effects to less than 30% for information on finances, chemoprevention and monitoring for signs of recurrence. No significant differences were found in the receipt of survivorship care information across demographic factors or cancer type. CONCLUSIONS: Findings suggest that cancer survivors living in rural areas are not consistently provided with adequate survivorship care information, particularly that pertaining to long-term health and recovery. IMPLICATIONS FOR CANCER SURVIVORS: Without improved systems for delivering survivorship care information to patients returning home to rural communities after treatment, these cancer survivors risk missing out on necessary information and advice to maintain their health, wellbeing and long-term recovery.

Establishing a Working Definition of User Experience for eHealth Interventions of Self-reported User Experience Measures With eHealth Researchers and Adolescents: Scoping Review.

BACKGROUND: Across eHealth intervention studies involving children, adolescents, and their parents, researchers have measured user experience to assist with intervention development, refinement, and evaluation. To date, no widely accepted definitions or measures of user experience exist to support a standardized approach for evaluation and comparison within or across interventions. OBJECTIVE: We conduct a scoping review with subsequent Delphi consultation to identify how user experience is defined and measured in eHealth research studies, characterize the measurement tools used, and establish working definitions for domains of user experience that could be used in future eHealth evaluations. METHODS: We systematically searched electronic databases for published and gray literature available from January 1, 2005, to April 11, 2019. We included studies assessing an eHealth intervention that targeted any health condition and was designed for use by children, adolescents, and their parents. eHealth interventions needed to be web-, computer-, or mobile-based, mediated by the internet with some degree of interactivity. We required studies to report the measurement of user experience as first-person experiences, involving cognitive and behavioral factors reported by intervention users. We appraised the quality of user experience measures in included studies using published criteria: well-established, approaching well-established, promising, or not yet established. We conducted a descriptive analysis of how user experience was defined and measured in each study. Review findings subsequently informed the survey questions used in the Delphi consultations with eHealth researchers and adolescent users for how user experience should be defined and measured. RESULTS: Of the 8634 articles screened for eligibility, 129 articles and 1 erratum were included in the review. A total of 30 eHealth researchers and 27 adolescents participated in the Delphi consultations. On the basis of the literature and consultations, we proposed working definitions for 6 main user experience domains: acceptability, satisfaction, credibility, usability, user-reported adherence, and perceived impact. Although most studies incorporated a study-specific measure, we identified 10 well-established measures to quantify 5 of the 6 domains of user experience (all except for self-reported adherence). Our adolescent and researcher participants ranked perceived impact as one of the most important domains of user experience and usability as one of the least important domains. Rankings between adolescents and researchers diverged for other domains. CONCLUSIONS: Findings highlight the various ways in which user experience has been defined and measured across studies and what aspects are most valued by researchers and adolescent users. We propose incorporating the working definitions and available measures of user experience to support consistent evaluation and reporting of outcomes across studies. Future studies can refine the definitions and measurement of user experience, explore how user experience relates to other eHealth outcomes, and inform the design and use of human-centered eHealth interventions.

Trajectories of Change in an Open-access Internet-Based Cognitive Behavior Program for Childhood and Adolescent Anxiety: Open Trial.

BACKGROUND: Although evidence bolstering the efficacy of internet-based cognitive behavioral therapy (iCBT) for treating childhood anxiety has been growing continuously, there is scant empirical research investigating the timing of benefits made in iCBT programs (eg, early or delayed). OBJECTIVE: This study aims to examine the patterns of symptom trajectories (changes in anxiety) across an iCBT program for anxiety (BRAVE Self-Help). METHODS: This study's participants included 10,366 Australian youth aged 7 to 17 years (4140 children aged 7-12 years; 6226 adolescents aged 12-17 years) with elevated anxiety who registered for the BRAVE Self-Help program. Participants self-reported their anxiety symptoms at baseline or session 1 and then at the commencement of each subsequent session. RESULTS: The results show that young people completing the BRAVE Self-Help program tend to fall into two trajectory classes that can be reliably identified in terms of high versus moderate baseline levels of anxiety and subsequent reduction in symptoms. Both high and moderate anxiety severity trajectory classes showed significant reductions in anxiety, with the greatest level of change being achieved within the first six sessions for both classes. However, those in the moderate anxiety severity class tended to show reductions in anxiety symptoms to levels below the elevated range, whereas those in the high symptom group tended to remain in the elevated range despite improvements. CONCLUSIONS: These findings suggest that those in the high severity group who do not respond well to iCBT on a self-help basis may benefit from the additional support provided alongside the program or a stepped-care approach where progress is monitored and support can be provided as necessary.

Cancer-related help-seeking in cancer survivors living in regional and remote Australia.

OBJECTIVES: To measure rates of detection via screening, perceived self-imposed delays in seeking medical attention, and support seeking in a sample of regional and remote people with a cancer diagnosis and to test whether an association exists between these behaviours and minimising problems and resignation, a need for self-control and reliance and fatalism. Correlations and binary logistic regressions were conducted to test the associations between demographic characteristics, attitudes and behaviours. RESULTS: Females were more likely to have had their cancer detected via screening (OR = 10.02, CI = 3.49-28.78). Younger participants (r = -0.103, p = 0.009) were slightly more likely to seek at least one form of support and online support was sought more often by younger patients (r = -0.269, p < 0.001), females (r = 0.152, p < 0.001), those from higher socio-economic (SES) areas (r = 0.100, p = 0.012), and those with higher education levels (r = 0.247, p < 0.001). Younger (r = -0.161, p < 0.001), and female (r = 0.82, p = 0.013), participants were also slightly more likely to seek support specifically through cancer support groups. No significant relationships between minimising problems and resignation, needs for control and self-reliance or fatalism and detection via screening, support seeking, or perceived self-imposed delays to seeking medical attention were apparent, with the exception that those with higher fatalism (predetermined health) were slightly less likely to report seeking support or information online (OR = 0.79, CI = 0.65-0.95) and slightly more likely to report using Cancer Council's support services (OR = 1.24, CI = 1.02-1.52). CONCLUSIONS: Strategies to improve the accessibility and appropriateness of support available for regional and remote cancer patients should consider interventions that remove barriers to access associated with age, gender, and education as opposed to those which address the attitudinal traits measured here.

Are National Cancer Control Indicators for patient experiences being met in regional and remote Australia? A cross-sectional study of cancer survivors who travelled for treatment.

OBJECTIVE: To examine the health services experience of patients with cancer from regional and remote Australia using the Australian National Cancer Control Indicators (NCCI) guidelines as an assessment framework. DESIGN: Cross-sectional. SETTING: Queensland non-for-profit cancer accommodation lodges. PARTICIPANTS: Participants were patients with cancer who travelled for treatment from rural and remote Queensland to major urban centres (n=518; age mean=64.6, SD=11.18). OUTCOME MEASURES: Assessments included NCCI patient indicators, quality of life (QoL), psychological distress and unmet supportive care needs. RESULTS: The frequency at which NCCI indicators were met ranged from 37.5% for receiving an assessment and care plan to 97.3% for understanding explanations about diagnosis. Geographical considerations did not impact patient experience, whereas middle school educated participants were more likely than those with senior-level education or higher to receive an assessment and care plan (OR=1.90, 95% CI 1.23 to 2.91) and to report having their views on treatment taken into account (OR=2.22, 95% CI 1.49 to 3.33). Patients with breast or prostate cancer reported better communication and patient involvement and information and services provision (r=p<0.001) compared with those with skin and head and neck cancer. When compared with information and service provision, communication and patient involvement showed stronger positive associations with QoL (z=2.03, p=0.042), psychosocial (z=2.05, p=0.040) and patient care (z=2.00, p=0.046) outcomes. CONCLUSION: The patient care experience varies across the NCCI indicators by sociodemographic and clinical factors that likely reflect healthcare system biases. Perceptions about communication and involvement appear most critical for optimal outcomes and should be a priority action area for cancer control.

Online physical activity and sedentary behaviour information for cancer survivors.

PURPOSE: The purpose of this study is to assess the prevalence, content, and nature of information and/or advice regarding physical activity and sedentary behaviour available online for cancer survivors. METHODS: A search strategy was designed to identify website links that were most likely to be accessed by cancer survivors, living in five English speaking nations, looking for information about maintaining and improving health after a cancer diagnosis. All content pertaining to physical activity and sedentary behaviour was extracted, and proportions of website links containing key information were calculated. Content analysis was performed on the data to describe the nature of information provided. RESULTS: Of the 394 website links reviewed, 73.4% contained information about physical activity; however, most websites did not detail recommendations, strategies and potential risks of engaging in physical activity. Less than 10% of the links reviewed contained information about sedentary behaviour. Results varied according to website and cancer type. CONCLUSIONS: Although the importance of physical activity is frequently mentioned, online content on the subject lacks comprehensive, specific advice. Health advice online for cancer survivors regarding the importance of avoiding sedentary behaviour is scarce with little to no detail on how to achieve this. IMPLICATION OF CANCER SURVIVORS: Until website conveners improve the comprehensiveness and specificity of the information they provide, cancer survivors may find it difficult to find, via the Internet, the advice required to properly guide and facilitate their safe participation in physical activity and avoidance of sedentary behaviour.

Geographical Disparities in Screening and Cancer-Related Health Behaviour.

This study aimed to identify whether cancer-related health behaviours including participation in cancer screening vary by geographic location in Australia. Data were obtained from the 2014-2015 Australian National Health Survey, a computer-assisted telephone interview that measured a range of health-related issues in a sample of randomly selected households. Chi-square tests and adjusted odds ratios from logistic regression models were computed to assess the association between residential location and cancer-related health behaviours including cancer screening participation, alcohol consumption, smoking, exercise, and fruit and vegetable intake, controlling for age, socio-economic status (SES), education, and place of birth. The findings show insufficient exercise, risky alcohol intake, meeting vegetable intake guidelines, and participation in cervical screening are more likely for those living in inner regional areas and in outer regional/remote areas compared with those living in major cities. Daily smoking and participation in prostate cancer screening were significantly higher for those living in outer regional/remote areas. While participation in cancer screening in Australia does not appear to be negatively impacted by regional or remote living, lifestyle behaviours associated with cancer incidence and mortality are poorer in regional and remote areas. Population-based interventions targeting health behaviour change may be an appropriate target for reducing geographical disparities in cancer outcomes.

Geographical Variations in the Clinical Management of Colorectal Cancer in Australia: A Systematic Review.

BACKGROUND: In Australia, cancer survival is significantly lower in non-metropolitan compared to metropolitan areas. Our objective was to evaluate the evidence on geographical variations in the clinical management and treatment of colorectal cancer (CRC). METHODS: A systematic review of published and gray literature was conducted. Five databases (CINAHL, PubMed, Embase, ProQuest, and Informit) were searched for articles published in English from 1990 to 2018. Studies were included if they assessed differences in clinical management according to geographical location; focused on CRC patients; and were conducted in Australia. Included studies were critically appraised using a modified Newcastle-Ottawa Scale. PRISMA systematic review reporting methods were applied. RESULTS: 17 articles met inclusion criteria. All were of high (53%) or moderate (47%) quality. The evidence available may suggest that patients in non-metropolitan areas are more likely to experience delays in surgery and are less likely to receive chemotherapy for stage III colon cancer and adjuvant radiotherapy for rectal cancer. CONCLUSION: The present review found limited information on clinical management across geographic regions in Australia and the synthesis highlights significant issues both for data collection and reporting at the population level, and for future research in the area of geographic variation. Where geographical disparities exist, these may be due to a combination of patient and system factors reflective of location. It is recommended that population-level data regarding clinical management of CRC be routinely collected to better understand geographical variations and inform future guidelines and policy.

Attitudes Toward e-Mental Health Services in a Community Sample of Adults: Online Survey.

BACKGROUND: Despite evidence that e-mental health services are effective, consumer preferences still appear to be in favor of face-to-face services. However, the theory of planned behavior (TPB) suggests that cognitive intentions are more proximal to behavior and thus may have a more direct influence on service use. Investigating individual characteristics that influence both preferences and intentions to use e-mental health services is important for better understanding factors that might impede or facilitate the use of these services. OBJECTIVE: This study explores predictors of preferences and intentions to access e-mental health services relative to face-to-face services. Five domains were investigated (demographics, technology factors, personality, psychopathology, and beliefs), identified from previous studies and informed by the Internet interventions model. We expected that more participants would report intentions to use e-mental health services relative to reported preferences for this type of support and that these 5 domains would be significantly associated with both intentions and preferences toward online services. METHODS: A mixed sample of 308 community members and university students was recruited through social media and the host institution in Australia. Ages ranged between 17 and 68 years, and 82.5% (254/308) were female. Respondents completed an online survey. Chi-square analysis and t tests were used to explore group differences, and logistic regression models were employed to explore factors predicting preferences and intentions. RESULTS: Most respondents (85.7%, 264/308) preferred face-to-face services over e-mental health services. Relative to preferences, a larger proportion of respondents (39.6%, 122/308) endorsed intentions to use e-mental health services if experiencing mental health difficulties in the future. In terms of the 5 predictor domains, 95% CIs of odds ratios (OR) derived from bootstrapped standard errors suggested that prior experience with online services significantly predicted intentions to use self-help (95% CI 2.08-16.24) and therapist-assisted (95% CI 1.71-11.90) online services in future. Being older predicted increased intentions to use therapist-assisted online services in future (95% CI 1.01-1.06), as did more confidence using computers and the Internet (95% CI 1.06-2.69). Technology confidence was also found to predict greater preference for online services versus face-to-face options (95% CI 1.24-4.82), whereas higher doctor-related locus of control, or LOC (95% CI 0.76-0.95), and extraversion (95% CI 0.88-1.00) were predictive of lower likelihood of preferring online services relative to face-to-face services. CONCLUSIONS: Despite generally low reported preferences toward e-mental health services, intentions to access these services are higher, raising the question of how to best encourage translation of intentions into behavior (ie, actual use of programs). Strategies designed to ease people into new Internet-based mental health programs (to enhance confidence and familiarity) may be important for increasing the likelihood that they will return to such programs later.