Increased diagnosis of attention-deficit hyperactivity disorder despite stable hyperactive/inattentive behaviours: evidence from two birth cohorts of Australian children.

BACKGROUND: Globally, ADHD diagnoses have increased substantially and there is concern that this trend does not necessarily reflect improved detection of cases but that overdiagnosis may be occurring. We directly compared ADHD diagnoses with ADHD-related behaviours and looked for changes across time among Australian children in a large, population-based prospective cohort study. METHODS: We conducted a secondary analysis of the Longitudinal Study of Australian Children, including 4,699 children born 1999/2000 (cohort 1) and 4,425 children born 2003/2004 (cohort 2), followed from 4 to 13 years of age. We compared pre-diagnosis parent-reported hyperactive/inattentive behaviour scores between newly diagnosed (incident cases) and undiagnosed children and fitted Cox's proportional hazards regression models to examine the relationship between birth cohorts 1 and 2 and the risk of incident ADHD diagnosis. RESULTS: Cumulative incident ADHD diagnoses increased from 4.6% in cohort 1 (born in 1999/2000) to 5.6% in cohort 2 (born in 2003/2004), while hyperactive/inattentive behaviour scores remained steady. Among ADHD diagnosed children, 26.5% (88/334) recorded pre-diagnosis behaviours in the normal range, 27.6% (n = 92) had borderline scores and 45.8% (n = 153) scored within the clinical range. Children born in 2003/2004 were more likely to be diagnosed with ADHD compared with those born in 1999/2000 (aHR = 1.33, 95% CI = 1.06-1.67, p = .012), regardless of their ADHD behaviour score (p = .972). CONCLUSIONS: Diagnostic increases were not driven by rises in hyperactive/inattentive behaviours. A quarter of all children with an ADHD diagnosis recorded pre-diagnosis behaviours within the normal range. The increased likelihood of being diagnosed with ADHD for children from the later birth cohort was observed for children across the full range of ADHD-related behaviours.

Implementation of risk stratification within bowel cancer screening: a community jury study exploring public acceptability and communication needs.

BACKGROUND: Population-based cancer screening programmes are shifting away from age and/or sex-based screening criteria towards a risk-stratified approach. Any such changes must be acceptable to the public and communicated effectively. We aimed to explore the social and ethical considerations of implementing risk stratification at three different stages of the bowel cancer screening programme and to understand public requirements for communication. METHODS: We conducted two pairs of community juries, addressing risk stratification for screening eligibility or thresholds for referral to colonoscopy and screening interval. Using screening test results (where applicable), and lifestyle and genetic risk scores were suggested as potential stratification strategies. After being informed about the topic through a series of presentations and discussions including screening principles, ethical considerations and how risk stratification could be incorporated, participants deliberated over the research questions. They then reported their final verdicts on the acceptability of risk-stratified screening and what information should be shared about their preferred screening strategy. Transcripts were analysed using codebook thematic analysis. RESULTS: Risk stratification of bowel cancer screening was acceptable to the informed public. Using data within the current system (age, sex and screening results) was considered an obvious next step and collecting additional data for lifestyle and/or genetic risk assessment was also preferable to age-based screening. Participants acknowledged benefits to individuals and health services, as well as articulating concerns for people with low cancer risk, potential public misconceptions and additional complexity for the system. The need for clear and effective communication about changes to the screening programme and individual risk feedback was highlighted, including making a distinction between information that should be shared with everyone by default and additional details that are available elsewhere. CONCLUSIONS: From the perspective of public acceptability, risk stratification using current data could be implemented immediately, ahead of more complex strategies. Collecting additional data for lifestyle and/or genetic risk assessment was also considered acceptable but the practicalities of collecting such data and how the programme would be communicated require careful consideration.

The impact of health literacy on psychosocial and behavioural outcomes among people at low risk of cardiovascular disease.

This study aimed to explore the impact of health literacy on psychosocial and behavioural outcomes for people who were not at high risk of cardiovascular disease receiving a hypothetical blood pressure reading of 135/85 mmHg. We performed a secondary analysis of data from a national sample of Australians aged 40 to 50 years (n = 1318) recruited online. Health literacy was measured using the validated Newest Vital Sign (inadequate: 0-3; adequate: 4-6). Analysed outcomes included: willingness to increase exercise and accept medication; perceived severity; positive and negative affect; illness perceptions and impacts on life and motivation. Participants with inadequate levels of health literacy perceived a blood pressure reading of 135/85 mmHg to be less serious compared to individuals with adequate health literacy (Mean Difference [MD]:0.21; 95%CI 0.03-0.39; p = .024; d = 0.13), and reported less motivation to eat well (MD:0.44; 95%CI 0.31-0.58; p < .001; d = 0.38) and exercise (MD:0.43; 95%CI 0.31-0.58; p < .001; d = 0.36). However, they were more willing to accept medication (MD:0.20; 95%CI 0.07-0.34; p = .004; d = 0.17). Participants with inadequate health literacy also perceived the condition to have fewer negative impacts on aspects of life and work than individuals with adequate health literacy, but reported greater negative emotion and more negative illness perceptions (all p < .001). Tailored communication and behaviour change support may be needed when communicating blood pressure information to people with lower health literacy and not at high risk of cardiovascular disease given the differential impacts on medication (increased willingness) and healthy exercise and diet behaviours (decreased willingness) observed in this study.

A community jury study exploring the public acceptability of using risk stratification to determine eligibility for cancer screening.

INTRODUCTION: Using risk stratification to determine eligibility for cancer screening is likely to improve the efficiency of screening programmes by targeting resources towards those most likely to benefit. We aimed to explore the implications of this approach from a societal perspective by understanding public views on the most acceptable stratification strategies. METHODS: We conducted three online community juries with 9 or 10 participants in each. Participants were purposefully sampled by age (40-79 years), sex, ethnicity, social grade and English region. On the first day, participants were informed of the potential benefits and harms of cancer screening and the implications of different ways of introducing stratification using scenarios based on phenotypic and genetic risk scores. On the second day, participants deliberated to reach a verdict on the research question, 'Which approach(es) to inviting people to screening are acceptable, and under what circumstances?' Deliberations and feedback were recorded and analysed using thematic analysis. RESULTS: Across the juries, the principle of risk stratification was generally considered to be an acceptable approach for determining eligibility for screening. Disregarding increasing capacity, the participants considered it to enable efficient resource allocation to high-risk individuals and could see how it might help to save lives. However, there were concerns regarding fair implementation, particularly how the risk assessment would be performed at scale and how people at low risk would be managed. Some favoured using the most accurate risk prediction model whereas others thought that certain risk factors should be prioritized (particularly factors considered as non-modifiable and relatively stable, such as genetics and family history). Transparently justifying the programme and public education about cancer risk emerged as important contributors to acceptability. CONCLUSION: Using risk stratification to determine eligibility for cancer screening was acceptable to informed members of the public, particularly if it included risk factors they considered fair and when communicated transparently. PATIENT OR PUBLIC CONTRIBUTION: Two patient and public involvement representatives were involved throughout this study. They were not involved in synthesizing the results but contributed to producing study materials, co-facilitated the community juries and commented on the interpretation of the findings and final report.

Public and patient perceptions of diagnostic labels for non-specific low back pain: a content analysis.

PURPOSE: An online randomised experiment found that the labels lumbar sprain, non-specific low back pain (LBP), and episode of back pain reduced perceived need for imaging, surgery and second opinions compared to disc bulge, degeneration, and arthritis among 1447 participants with and without LBP. They also reduced perceived seriousness of LBP and increased recovery expectations. METHODS: In this study we report the results of a content analysis of free-text data collected in our experiment. We used two questions: 1. When you hear the term [one of the six labels], what words or feelings does this make you think of? and 2. What treatment (s) (if any) do you think a person with [one of the six labels] needs? Two independent reviewers analysed 2546 responses. RESULTS: Ten themes emerged for Question1. Poor prognosis emerged for disc bulge, degeneration, and arthritis, while good prognosis emerged for lumbar sprain, non-specific LBP, and episode of back pain. Thoughts of tissue damage were less common for non-specific LBP and episode of back pain. Feelings of uncertainty frequently emerged for non-specific LBP. Twenty-eight treatments emerged for Question2. Surgery emerged for disc bulge, degeneration, and arthritis compared to lumbar sprain, non-specific LBP, and episode of back pain. Surgery did not emerge for non-specific LBP and episode of back pain. CONCLUSION: Our results suggest that clinicians should consider avoiding the labels disc bulge, degeneration and arthritis and opt for labels that are associated with positive beliefs and less preference for surgery, when communicating with patients with LBP.

A Community Jury on initiating weight management conversations in primary care.

BACKGROUND: Current guidelines recommend that patients attending general practice should be screened for excess weight, and provided with weight management advice. OBJECTIVE: This study sought to elicit the views of people with overweight and obesity about the role of GPs in initiating conversations about weight management. METHODS: Participants with a body mass index ≥25 were recruited from a region in Australia to take part in a Community Jury. Over 2 days, participants (n = 11) deliberated on two interconnected questions: 'Should GPs initiate discussions about weight management?' And 'if so, when: (a) opportunistically, (b) in the context of disease prevention, (c) in the context of disease management or (d) other?' The jury deliberations were analysed qualitatively to elicit their views and recommendations. RESULTS: The jury concluded GPs should be discussing weight management, but within the broader context of general health. The jury were divided about the utility of screening. Jurors felt GPs should initiate the conversation if directly relevant for disease prevention or management, otherwise GPs should provide opportunities for patients to consent to the issue being raised. CONCLUSION: The jury's verdict suggests informed people affected by overweight and obesity believe GPs should discuss weight management with their patients. GPs should feel reassured that discussions are likely to be welcomed by patients, particularly if embedded within a more holistic focus on person-centred care. PUBLIC CONTRIBUTION: Members of the public took part in the conduct of this study as jurors, but were not involved in the design, analysis or write-up.

Women's experiences of a diagnosis of gestational diabetes mellitus: a systematic review.

BACKGROUND: Gestational diabetes mellitus (GDM) - a transitory form of diabetes induced by pregnancy - has potentially important short and long-term health consequences for both the mother and her baby. There is no globally agreed definition of GDM, but definition changes have increased the incidence in some countries in recent years, with some research suggesting minimal clinical improvement in outcomes. The aim of this qualitative systematic review was to identify the psychosocial experiences a diagnosis of GDM has on women during pregnancy and the postpartum period. METHODS: We searched CINAHL, EMBASE, MEDLINE and PsycINFO databases for studies that provided qualitative data on the psychosocial experiences of a diagnosis of GDM on women across any stage of pregnancy and/or the postpartum period. We appraised the methodological quality of the included studies using the Critical Appraisal Skills Programme Checklist for Qualitative Studies and used thematic analysis to synthesis the data. RESULTS: Of 840 studies identified, 41 studies of diverse populations met the selection criteria. The synthesis revealed eight key themes: initial psychological impact; communicating the diagnosis; knowledge of GDM; risk perception; management of GDM; burden of GDM; social support; and gaining control. The identified benefits of a GDM diagnosis were largely behavioural and included an opportunity to make healthy eating changes. The identified harms were emotional, financial and cultural. Women commented about the added responsibility (eating regimens, appointments), financial constraints (expensive food, medical bills) and conflicts with their cultural practices (alternative eating, lack of information about traditional food). Some women reported living in fear of risking the health of their baby and conducted extreme behaviours such as purging and starving themselves. CONCLUSION: A diagnosis of GDM has wide reaching consequences that are common to a diverse group of women. Threshold cut-offs for blood glucose levels have been determined using the risk of physiological harms to mother and baby. It may also be advantageous to consider the harms and benefits from a psychosocial and a physiological perspective. This may avoid unnecessary burden to an already vulnerable population.

Exploring women's priorities for the potential consequences of a gestational diabetes diagnosis: A pilot community jury.

BACKGROUND: There is no international diagnostic agreement for gestational diabetes mellitus (GDM). In 2014, Australia adopted a new definition and testing procedure. Since then, significantly more women have been diagnosed with GDM but with little difference in health outcomes. We explored the priorities and preferences of women potentially impacted by a GDM diagnosis. METHOD: We recruited 15 women from the Gold Coast, Australia, to participate in a pilot community jury (CJ). Over two days, the women deliberated on the following: (a) which important consequences of a diagnosis of GDM should be considered when defining GDM?; (b) what should Australian health practitioners call the condition known as GDM? RESULTS: Eight women attended the pilot CJ, and their recommendations were a consensus. Women were surprised that the level of risk for physical harms was low but emotional harms were high. The final ranking of important consequences (high to low) was as follows: women's negative emotions; management burden of GDM; overmedicalized pregnancy; minimizing infant risks; improving lifestyle; and macrosomia. To describe the four different clinical states of GDM, the women chose three different labels. One was GDM. CONCLUSIONS: The women from this pilot CJ prioritized the consequences of a diagnosis of GDM differently from clinicians. The current glucose threshold for GDM in Australia is set at a cut-point for adverse risks including macrosomia and neonatal hyperinsulinaemia. Definitions and guideline panels often fail to ask the affected public about their values and preferences. Community voices impacted by health policies should be embedded in the decision-making process.

Efficacy of habit-based weight loss interventions: a systematic review and meta-analysis.

Habit-based interventions are a novel and emerging strategy to help reduce excess weight in individuals with overweight or obesity. This systematic review and meta-analysis aims to determine the efficacy of habit-based interventions on weight loss. We identified potential studies through electronic searches in February 2019. Included studies were randomized/quasi randomized controlled trials comparing weight loss interventions founded on habit-theory with a control (active or non-active) and enrolled adults with overweight or obesity (body mass index ≥ 25 kg/m2). Five trials (630 participants) met our inclusion criteria. After the intervention period (range 8-14 weeks), weight loss was modest but statistically different between groups (1.4 kg [95% confidence interval 0.5, 2.3; P = 0.004]) favoring habit-based interventions. Intervention groups averaged 2.5 kg weight loss (range 1.7 to 6.7 kg) compared with control 1.5 kg (range 0.4 to 5.8 kg) and were 2.4 times more likely to achieve clinically beneficial weight loss (≥ 5% weight reduction). Average weight losses in adults with overweight and obesity using habit-based interventions appear to be of clinical benefit. There were statistically significant differences in weight loss between habit-based interventions and controls, post-intervention. Longer studies powered to examine at least 12-month follow-up are required to more accurately determine the role of habit-based interventions on long-term weight loss maintenance.Trial registration Prospero ID: CRD42017065589. Available from https://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42017065589 .

Habit-based interventions for weight loss maintenance in adults with overweight and obesity: a randomized controlled trial.

OBJECTIVES: The objective of this study was to determine whether habit-based interventions are clinically beneficial in achieving long-term (12-month) weight loss maintenance and explore whether making new habits or breaking old habits is more effective. METHODS: Volunteer community members aged 18-75 years who had overweight or obesity (BMI ≥ 25 kg/m2) were randomized in a single-blind, three-arm, randomized controlled trial. Ten Top Tips (TTT), Do Something Different (DSD), and the attention-only waitlist (WL) control groups were conducted for 12 weeks from July to October 2015. Participants were followed up post-intervention (all groups) and at 6 and 12-month post-intervention (Ten Top Tips and Do Something Different only). The primary outcome was weight-loss maintenance at 12-month follow-up. Secondary outcomes included weight loss at all time points, fruit and vegetable consumption, exercise, wellbeing, depression, anxiety, habit strength, and openness to change. RESULTS: Of the 130 participants assessed for eligibility, 75 adults (mean BMI 34.5 kg/m2 [SD 6.2]), with a mean age of 51 years were recruited. Assessments were completed post-intervention by 66/75 (88%) of participants and by 43/50 (86%) at 12 months. At post-intervention, participants in the Ten Top Tips (-3.3 kg; 95% CI -5.2, -1.4) and Do Something Different (-2.9 kg; 95% CI -4.3, -1.4) interventions lost significantly more weight (P = < .001) than those on the waitlist control (-0.4 kg; 95% CI -1.2, 0.3). Both intervention groups continued to lose further weight to the 12-month follow-up; TTT lost an additional -2.4 kg (95% CI -5.1, 0.4) and DSD lost -1.7 kg (95% CI -3.4, -0.1). At 12-month post-intervention, 28/43 (65%) of participants in both intervention groups had reduced their total body weight by ≥5%, a clinically important change. CONCLUSIONS: Habit-based weight-loss interventions-forming new habits (TTT) and breaking old habits (DSD), resulted in clinically important weight-loss maintenance at 12-month follow-up.

A review of changes to the attention deficit/hyperactivity disorder age of onset criterion using the checklist for modifying disease definitions.

BACKGROUND: Widening definitions of health conditions have the potential to affect millions of people and should only occur when there is strong evidence of benefit. In the last version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the DSM-5 Committee changed the Attention Deficit Hyperactivity Disorder (ADHD) age of onset criterion in two ways: raising the age of symptom onset and removing the requirement for symptoms to cause impairment. Given concerns about ADHD prevalence and treatment rates, we aimed to evaluate the evidence available to support these changes using a recently developed Checklist for Modifying Disease Definitions. METHODS: We identified and analysed research informing changes to the DSM-IV-TR ADHD age of onset criterion. We compared this evidence to the evidence recommended in the Checklist for Modifying Disease Definitions. RESULTS: The changes to the DSM-IV-TR age of onset criterion were based on a literature review (publicly available as a 2 page document with online table of included studies), which we appraised as at high risk of bias. Estimates of the change in ADHD prevalence resulting from change to the age of onset criterion were based on a single study that included only a small number of children with ADHD (n = 68) and only assessed the impact of change to the age component of the criterion. No evidence was used by, or available to the Committee regarding the impact on prevalence of removal of the requirement for impairment, or the effect of the criterion changes on diagnostic precision, the prognosis of, or the potential benefits or harms for individuals diagnosed by the new, but not old criterion. CONCLUSIONS: The changes to the age of onset criterion were based on minimal research evidence that suffered from either high risk of bias or poor applicability. The minimal documentation available makes it difficult to judge the rigor of the process behind the criterion changes. Use of the Checklist for Modifying Disease Definitions would assist future proposed modifications of the DSM ADHD criteria, provide guidance on the studies needed to inform potential changes and would improve the transparency and documentation of the process.

Developing and applying a deductive coding framework to assess the goals of Citizen/Community Jury deliberations.

BACKGROUND: Public participation in health policy decision making is thought to improve the quality of the decisions and enhance their legitimacy. Citizen/Community Juries (CJs) are a form of public participation that aims to elicit an informed community perspective on controversial topics. Reporting standards for CJ processes have already been proposed. However, less clarity exists about the standards for what constitutes a good quality CJ deliberation-we aim to begin to address this gap here. METHODS: We identified the goals that underlie CJs and searched the literature to identify existing frameworks assessing the quality of CJ deliberations. We then mapped the items constituting these frameworks onto the CJ goals; where none of the frameworks addressed one of the CJ goals, we generated additional items that did map onto the goal. RESULTS: This yielded a single operationalized deductive coding framework, consisting of four deliberation elements and four recommendation elements. The deliberation elements focus on the following: jurors' preferences and values, engagement with each other, referencing expert information and enrichment of the deliberation. The recommendation elements focus on the following: reaching a clear and identifiable recommendation, whether the recommendation directly addresses the CJ question, justification for the recommendation and adoption of societal (rather than individual) perspective. To explore the alignment between this framework and the goals underlying CJs, we mapped the operationalized framework onto the transcripts of a CJ. CONCLUSION: Results suggest that framework items map well onto what transpires in an actual CJ deliberation. Further testing of the validity, generalizability and reliability of the framework is planned.

An Australian community jury to consider case-finding for dementia: Differences between informed community preferences and general practice guidelines.

BACKGROUND: Case-finding for dementia is practised by general practitioners (GPs) in Australia but without an awareness of community preferences. We explored the values and preferences of informed community members around case-finding for dementia in Australian general practice. DESIGN, SETTING AND PARTICIPANTS: A before and after, mixed-methods study in Gold Coast, Australia, with ten community members aged 50-70. INTERVENTION: A 2-day citizen/community jury. Participants were informed by experts about dementia, the potential harms and benefits of case-finding, and ethical considerations. PRIMARY AND SECONDARY OUTCOMES: We asked participants, "Should the health system encourage GPs to practice 'case-finding' of dementia in people older than 50?" Case-finding was defined as a GP initiating testing for dementia when the patient is unaware of symptoms. We also assessed changes in participant comprehension/knowledge, attitudes towards dementia and participants' own intentions to undergo case-finding for dementia if it were suggested. RESULTS: Participants voted unanimously against case-finding for dementia, citing a lack of effective treatments, potential for harm to patients and potential financial incentives. However, they recognized that case-finding was currently practised by Australian GPs and recommended specific changes to the guidelines. Participants increased their comprehension/knowledge of dementia, their attitude towards case-finding became less positive, and their intentions to be tested themselves decreased. CONCLUSION: Once informed, community jury participants did not agree case-finding for dementia should be conducted by GPs. Yet their personal intentions to accept case-finding varied. If case-finding for dementia is recommended in the guidelines, then shared decision making is essential.

Parent-Child Interaction Therapy Adapted for Preschoolers with Callous-Unemotional Traits: An Open Trial Pilot Study.

Children with co-occurring conduct problems and callous-unemotional (CU) traits show a distinct pattern of early starting, chronic, and aggressive antisocial behaviors that are resistant to traditional parent-training interventions. The aim of this study was to examine in an open trial the acceptability and initial outcomes of a novel adaptation of Parent-Child Interaction Therapy, called PCIT-CU, designed to target 3 distinct deficits of children with CU traits. Twenty-three Australian families with a 3- to 6-year-old (M age = 4.5 years, SD = .92) child with clinically significant conduct problems and CU traits participated in the 21-week intervention and 5 assessments measuring child conduct problems, CU traits, and empathy at a university-based research clinic. Treatment retention was high (74%), and parents reported a high level of satisfaction with the program. Results of linear mixed models indicated that the intervention produced decreases in child conduct problems and CU traits, and increases in empathy, with "medium" to "huge" effect sizes (ds = 0.7-2.0) that maintained at a 3-month follow-up. By 3 months posttreatment, 75% of treatment completers no longer showed clinically significant conduct problems relative to 25% of dropouts. Findings provide preliminary support for using the targeted PCIT-CU adaptation to treat young children with conduct problems and co-occurring CU traits.

The impact of a small-group educational intervention for allied health professionals to enhance evidence-based practice: mixed methods evaluation.

BACKGROUND: Healthcare professionals are recommended to use evidence-based practice (EBP) principles to update and improve clinical practice. Well-designed educational initiatives, together with practice and feedback opportunities can improve individuals' EBP knowledge, skills and attitudes. METHODS: A concurrent mixed methods assessment was designed to evaluate the effectiveness and feasibility of four monthly workshops on allied health professionals' knowledge, skills, self-efficacy and behaviour. In between workshops, professionals were encouraged to practice and integrate EBP learnings with colleagues in their workplace. Participants completed three pre and post intervention assessments: Evidence-based Practice Confidence Scale; adapted Fresno test; and an adapted EBP Implementation Scale. A purpose designed satisfaction questionnaire was completed immediately after the educational intervention and follow up focus groups were conducted after 3 months. Mean change in assessment data was quantitatively assessed and comments from the clinician satisfaction questionnaire and focus groups were thematically analysed and interpreted together with quantitative data using the Classification Rubric for EBP Assessment tools in Education (CREATE). RESULTS: Sixteen allied health professionals participated in the EBP workshops and completed all baseline and post intervention assessments. Seven clinicians participated in follow up focus groups. All clinicians reported a positive reaction to the learning experience, preferring short monthly workshops to a full day session. They self-reported improvements in self-efficacy (mean change 15 p < 0.001) and implementing EBP behaviours (mean change 7, p < 0.001) from pre- to post-intervention. Although the positive change in EBP knowledge measured by the adapted Fresno test was not statistically significant (mean change 10, p = 0.21), clinicians described examples of improved knowledge and skills across all five key steps of EBP during the focus groups. A further, post hoc analysis of individual questions in the two self-reported scales indicated consistent improvement across key EBP knowledge and skills. CONCLUSIONS: A tailored small group EBP education intervention can enhance AHPs' self-efficacy to develop answerable questions, search the literature, critically appraise, apply and evaluate research evidence. Through practicing these behaviours and sharing new learning with their peers, allied health professionals can enhance their capability and motivation to use research evidence to potentially improve clinical practice.

Factors that influence the sustainability of structured allied health journal clubs: a qualitative study.

BACKGROUND: Structured journal clubs are a widely used tool to promote evidence-based practice in health professionals, however some journal clubs (JC) are more effectively sustained than others. To date, little research has provided insights into factors which may influence sustainability of JCs within health care settings. As part of a larger randomised controlled study, this research aimed to gain understanding of clinicians' experiences of sustaining a structured JC format (TREAT- Tailoring Research Evidence and Theory) within their clinical context. The study also aimed to identify which strategies may assist longer term sustainability and future implementation of the TREAT format. METHODS: We employed a qualitative methodology, informed by behaviour change theory. Clinicians (n = 19) from five different JCs participated in focus groups to explore their experience in sustaining the JC format six months after the formal trial period had completed. Clinicians were asked to describe factors which they perceived helped or hindered sustaining components of the JC format within their local context. Following a descriptive summary of the data, barriers and enablers were thematically analysed according to behaviour change theory domains: capability, motivation and opportunity and further mapped to targeted implementation strategies. RESULTS: Participants reported perceived benefits of maintaining the TREAT format and described several components that promoted its sustainability. Sustaining factors linked to individuals' capability included building research knowledge and skills and having access to research experts. Sustaining factors that enhanced opportunities for behaviour change included management expectation to attend and a team culture which values evidence based practice, while factors found to enhance individuals' motivation included the JC having close application to practice and clinicians sensing ownership of the JC. Several implementation strategies to enhance these factors are described including graduated support to clinicians in facilitation of JCs and greater engagement with managers. CONCLUSIONS: Long-term sustainability of a structured JC is dependent on both individual and service level factors and a balance of implementation strategies that enhance capability, opportunity and motivation. Consideration of how clinicians can be engaged to take ownership and build their own capability from the commencement of the JC is important. TRIAL REGISTRATION: ACTRN12616000811404 .

The effectiveness and feasibility of TREAT (Tailoring Research Evidence and Theory) journal clubs in allied health: a randomised controlled trial.

BACKGROUND: Journal clubs (JC) may increase clinicians' evidence-based practice (EBP) skills and facilitate evidence uptake in clinical practice, however there is a lack of research into their effectiveness in allied health. We investigated the effectiveness of a structured JC that is Tailored According to Research Evidence And Theory (TREAT) in improving EBP skills and practice compared to a standard JC format for allied health professionals. Concurrently, we explored the feasibility of implementing TREAT JCs in a healthcare setting, by evaluating participating clinicians' perceptions and satisfaction. METHODS: We conducted an explanatory mixed methods study involving a cluster randomised controlled trial with a nested focus group for the intervention participants. Nine JCs with 126 allied health participants were randomly allocated to receive either the TREAT or standard JC format for 1 h/month for 6 months. We conducted pre-post measures of EBP skills and attitudes using the EBP questionnaire and Assessing Competence in Evidence-Based Medicine tool and a tailored satisfaction and practice change questionnaire. Post-intervention, we also conducted a focus group with TREAT participants to explore their perceptions of the format. RESULTS: There were no significant differences between JC formats in EBP skills, knowledge or attitudes or influence on clinical practice, with participants maintaining intermediate level skills across time points. Participants reported significantly greater satisfaction with the organisation of the TREAT format. Participants in both groups reported positive changes to clinical practice. Perceived outcomes to the TREAT format and facilitating mechanisms were identified including the use of an academic facilitator, group appraisal approach and consistent appraisal tools which assisted skill development and engagement. CONCLUSIONS: It is feasible to implement an evidence-based JC for allied health clinicians. While clinicians were more satisfied with the TREAT format, it did not significantly improve their EBP skills, attitudes, knowledge and/or practice, when compared to the standard format. The use of an academic facilitator, group based critical appraisal, and the consistent use of appraisal tools were perceived as useful components of the JC format. A structured JC may maintain EBP skills in allied health clinicians and facilitate engagement, however additional training may be required to further enhance EBP skills. TRIAL REGISTRATION: ACTRN12616000811404 Retrospectively registered 21 June 2016.

CJCheck Stage 1: development and testing of a checklist for reporting community juries - Delphi process and analysis of studies published in 1996-2015.

BACKGROUND: Opportunities for community members to actively participate in policy development are increasing. Community/citizen's juries (CJs) are a deliberative democratic process aimed to illicit informed community perspectives on difficult topics. But how comprehensive these processes are reported in peer-reviewed literature is unknown. Adequate reporting of methodology enables others to judge process quality, compare outcomes, facilitate critical reflection and potentially repeat a process. We aimed to identify important elements for reporting CJs, to develop an initial checklist and to review published health and health policy CJs to examine reporting standards. DESIGN: Using the literature and expertise from CJ researchers and policy advisors, a list of important CJ reporting items was suggested and further refined. We then reviewed published CJs within the health literature and used the checklist to assess the comprehensiveness of reporting. RESULTS: CJCheck was developed and examined reporting of CJ planning, juror information, procedures and scheduling. We screened 1711 studies and extracted data from 38. No studies fully reported the checklist items. The item most consistently reported was juror numbers (92%, 35/38), while least reported was the availability of expert presentations (5%, 2/38). Recruitment strategies were described in 66% of studies (25/38); however, the frequency and timing of deliberations was inadequately described (29%, 11/38). CONCLUSIONS: Currently CJ publications in health and health policy literature are inadequately reported, hampering their use in policy making. We propose broadening the CJCheck by creating a reporting standards template in collaboration with international CJ researchers, policy advisors and consumer representatives to ensure standardized, systematic and transparent reporting.

An Evaluation of Parent-Child Interaction Therapy With and Without Motivational Enhancement to Reduce Attrition.

Although many interventions for child externalizing behavior report promising outcomes for families, high attrition prior to program completion remains a problem. Many programs report dropout rates of 50% or higher. In this trial we sought to reduce attrition and improve outcomes by augmenting a well-known evidence-based intervention, Parent-Child Interaction Therapy (PCIT), with a 3-session individual motivational enhancement component. Participants were 192 Australian caregivers (91.7% female; Mage = 34.4 years) and their children (33.3% female; Mage = 4.4 years). Families (51% referred from child welfare or health services for risk of maltreatment) were assigned to PCIT or a supported waitlist, with families assigned to PCIT receiving either standard PCIT (S/PCIT) or motivation-enhanced PCIT (M/PCIT), depending on their time of entry to the study. Waitlist families received phone calls every week for 12 weeks. Parents in M/PCIT reported more readiness to change their behavior from preassessment to after the motivation sessions. Also, parents who reported high, rather than low, motivation at preassessment did have a lower attrition rate, and there was some evidence that enhancing motivation was protective of premature attrition to the extent that caregivers achieved a high degree of change in motivation. Yet comparison of attrition rates and survival analyses revealed no difference between M/PCIT and S/PCIT in retention rate. Finally, there were greater reductions in externalizing and internalizing child behavior problems and parental stress among families in S/PCIT and M/PCIT compared with waitlist, and there was generally no significant difference between the two treatment conditions.