Randomized Trial of Information for Older Women About Cessation of Breast Cancer Screening Invitations.

BACKGROUND: Older women receive no information about why Australia's breast screening program (BreastScreen) invitations cease after 74 years. We tested how providing older women with the rationale for breast screening cessation impacted informed choice (adequate knowledge; screening attitudes aligned with intention). METHODS: In a three-arm online randomized trial, eligible participants were females aged 70-74 years who had recently participated in breast screening (within 5 years), without personal breast cancer history, recruited through Qualtrics. Participants read a hypothetical scenario in which they received a BreastScreen letter reporting no abnormalities on their mammogram. They were randomized to receive the letter: (1) without any rationale for screening cessation (control); (2) with screening cessation rationale in printed-text form (e.g., downsides of screening outweigh the benefits after age 74); or (3) with screening cessation rationale presented in an animation video form. The primary outcome was informed choice about continuing/stopping breast screening beyond 74 years. RESULTS: A total of 376 participant responses were analyzed. Compared to controls (n = 122), intervention arm participants (text [n = 132] or animation [n = 122]) were more likely to make an informed choice (control 18.0%; text 32.6%, p = .010; animation 40.5%, p < .001). Intervention arm participants had more adequate knowledge (control 23.8%; text 59.8%, p < .001; animation 68.9%, p < .001), lower screening intentions (control 17.2%; text 36.4%, p < .001; animation 49.2%, p < .001), and fewer positive screening attitudes regarding screening for themselves in the animation arm, but not in the text arm (control 65.6%; text 51.5%, p = .023; animation 40.2%, p < .001). CONCLUSIONS: Providing information to older women about the rationale for breast cancer screening cessation increased informed decision-making in a hypothetical scenario. This study is an important first step in improving messaging provided by national cancer screening providers direct to older adults. Further research is needed to assess the impact of different elements of the intervention and the impact of providing this information in clinical practice, with more diverse samples. TRIAL REGISTRATION: ANZCTRN12623000033640.

Lung cancer screening program factors that influence psychosocial outcomes: A systematic review.

OBJECTIVES: Lung cancer screening (LCS) programs are being designed and implemented globally. Early data suggests that the psychosocial impacts of LCS are influenced by program factors, but evidence synthesis is needed. This systematic review aimed to elucidate the impact of service-level factors on psychosocial outcomes to inform optimal LCS program design and future implementation. METHODS: Four databases were searched from inception to July 2023. Inclusion criteria were full-text articles published in English that reported an association between any program factors and psychosocial outcomes experienced during LCS. Study quality was appraised, and findings were synthesised narratively. RESULTS: Thirty-two articles were included; 29 studies were assessed at high or moderate risk of bias. Study designs were RCT (n = 3), pre-post (n = 6), cross-sectional (n = 12), mixed-methods (n = 1), and qualitative (n = 10) studies, and conducted primarily in the USA (n = 25). Findings suggested that targeted interventions can improve smoking-related or decisional psychosocial outcomes (e.g., smoking cessation interventions increase readiness/motivation to quit) but impacts of interventions on other psychological outcomes were varied. There was limited evidence reporting association between service delivery components and psychological outcomes, and results suggested moderation by individual aspects (e.g., expectation of results, baseline anxiety). Opportunities for discussion were key in reducing psychological harm. CONCLUSIONS: Certain program factors are reportedly associated with psychosocial impacts of LCS, but study heterogeneity and quality necessitate more real-world studies. Future work should examine (a) implementation of targeted interventions and high-value discussion during LCS, and (b) optimal methods and timing of risk and result communication, to improve psychosocial outcomes while reducing time burden for clinicians.

Factors Influencing Primary Care Practitioners' Cancer Screening Recommendations for Older Adults: a Systematic Review.

BACKGROUND: Primary care practitioners (PCPs) play a key role in cancer screening decisions for older adults (≥ 65 years), but recommendations vary by cancer type and jurisdiction. PURPOSE: To examine the factors influencing PCPs' recommendations for breast, cervical, prostate, and colorectal cancer screening for older adults. DATA SOURCES: MEDLINE, Pre-Medline, EMBASE, PsycINFO, and CINAHL, searched from 1 January 2000 to July 2021, and citation searching in July 2022. STUDY SELECTION: Assessed factors influencing PCPs' breast, prostate, colorectal, or cervical cancer screening decisions for older adults' (defined either as ≥ 65 years or < 10-year life expectancy). DATA EXTRACTION: Two authors independently conducted data extraction and quality appraisal. Decisions were crosschecked and discussed where necessary. DATA SYNTHESIS: From 1926 records, 30 studies met inclusion criteria. Twenty were quantitative, nine were qualitative, and one used a mixed method design. Twenty-nine were conducted in the USA, and one in the UK. Factors were synthesized into six categories: patient demographic characteristics, patient health characteristics, patient and clinician psycho-social factors, clinician characteristics, and health system factors. Patient preference was most reported as influential across both quantitative and qualitative studies. Age, health status, and life expectancy were also commonly influential, but PCPs held nuanced views about life expectancy. Weighing benefits/harms was also commonly reported with variation across cancer screening types. Other factors included patient screening history, clinician attitudes/personal experiences, patient/provider relationship, guidelines, reminders, and time. LIMITATIONS: We could not conduct a meta-analysis due to variability in study designs and measurement. The vast majority of included studies were conducted in the USA. CONCLUSIONS: Although PCPs play a role in individualizing cancer screening for older adults, multi-level interventions are needed to improve these decisions. Decision support should continue to be developed and implemented to support informed choice for older adults and assist PCPs to consistently provide evidence-based recommendations. REGISTRATION: PROSPERO CRD42021268219. FUNDING SOURCE: NHMRC APP1113532.

Education messages and strategies to inform the public, potential screening candidates and healthcare providers about lung cancer screening: A systematic review.

International lung cancer screening (LCS) trials, using low-dose computed tomography, have demonstrated clinical effectiveness in reducing mortality from lung cancer. This systematic review aims to synthesise the key messages and strategies that could be successful in increasing awareness and knowledge of LCS, and ultimately increase uptake of screening. Studies were identified via relevant database searches up to January 2022. Two authors evaluated eligible studies, extracted and crosschecked data, and assessed quality. Results were synthesised narratively. Of 3205 titles identified, 116 full text articles were reviewed and 22 studies met the inclusion criteria. Twenty studies were conducted in the United States. While the study findings were heterogenous, key messages mentioned across multiple studies were about: provision of information on LCS and the recommendations for LCS (n = 8); benefits and harms of LCS (n = 6); cost of LCS and insurance coverage for participants (n = 6) and eligibility criteria (n = 5). To increase knowledge and awareness, evidence from awareness campaigns suggests that presenting information about eligibility and the benefits and harms of screening, may increase screening intention and uptake. Evidence from behavioural studies suggests that campaigns supporting engagement with platforms such as educational videos and digital awareness campaigns might be most effective. Group based learning appears to be most suited to increasing health professionals' knowledge. This systematic review found a lack of consistent evidence to demonstrate which strategies are most effective for increasing participant healthcare professional and community awareness and education about LCS.

An education resource for human papillomavirus oropharyngeal cancer patients: think-aloud interviews.

PURPOSE: The human papillomavirus (HPV) is well recognised as a factor in developing oropharyngeal cancer (OPC). A booklet for HPV-OPC patients aimed to deliver evidence-based messages in everyday language, in a way to minimise negative psychological impacts on patients. Our study explored the suitability of the booklet for use. METHODS: Participants were recruited through social media and interviewed via Zoom. Participants were shown the booklet and a think-aloud method elicited real-time reactions to the content. Responses were analysed for each section and coded as either for or against for content, with other responses thematically analysed using NVivo. RESULTS: The sample comprised 24 participants: patients (n = 19) who completed treatment for HPV-OPC and partners of survivors of HPV-OPC (n = 5). All participants found the booklet useful, and most wished the resource had been available previously. Some indicated the information was new to them. The majority agreed the booklet would be best delivered by their specialist at point of diagnosis and would be a useful resource for friends and family. Most participants gave feedback on improvements to the booklet in terms of comprehension and design. Overall, participants found the content easy to understand. Most participants found that it helped to reduce shame and stigma associated with HPV as a sexually transmitted infection. CONCLUSION: An evidence-based booklet for HPV-OPC patients and their partners is acceptable. Implementation may be feasible in routine clinical practice, specifically at time of diagnosis. Adapting the content will help optimise the efficacy of the booklet in facilitating communication between all stakeholders.

Screening for cancer beyond recommended upper age limits: views and experiences of older people.

BACKGROUND: Internationally, screening programmes and clinical practice guidelines recommend when older adults should stop cancer screening using upper age limits, but it is unknown how older adults view these recommendations. OBJECTIVE: To examine older adults' views and experiences about continuing or stopping cancer screening beyond the recommended upper age limit for breast, cervical, prostate and bowel cancer. DESIGN: Qualitative, semi-structured interviews. SETTING: Australia, telephone. SUBJECTS: A total of 29 community-dwelling older adults (≥70-years); recruited from organisation newsletters, mailing lists and Facebook advertisements. METHODS: Interviews were audio-recorded, transcribed and analysed thematically using Framework Analysis. RESULTS: Firstly, older adults were on a spectrum between trusting recommendations and actively deciding about cancer screening, with some who were uncertain. Secondly, participants reported limited in-depth discussions with health professionals about cancer screening. In primary care, discussions were focused on checking they were up to date with screening or going over results. Discussions mostly only occurred if older adults initiated themselves. Finally, participants had a socially- and self-constructed understanding of screening recommendations and potential outcomes. Perceived reasons for upper age limits were cost, reduced cancer risk or ageism. Risks of screening were understood in relation to their own social experiences (e.g. shared stories about friends with adverse outcomes of cancer treatment or conversations with friends/family about controversy around prostate screening). CONCLUSIONS: Direct-to-patient information and clinician support may help improve communication about the changing benefit to harm ratio of cancer screening with increasing age and increase understanding about the rationale for an upper age limit for cancer screening programmes.

"I haven't had that information, even though I think I'm really well-informed about most things": a qualitative focus group study on Australian women's understanding and views of potentially modifiable risk factors for breast cancer.

BACKGROUND: Building health literacy about potentially modifiable risk factors for breast cancer may help to empower women to make more informed decisions about their breast health; however there has been limited qualitative research on this topic. This study aimed to explore current knowledge, understanding and experience of potentially modifiable risk factors for breast cancer, and views on current and future communication strategies for this information and related interventions. METHODS: Qualitative study using online focus groups via Zoom in October-November 2022. A diverse sample of women from the Australian community aged 40-74 years were recruited. RESULTS: Fifty-one women from a range of socioeconomic backgrounds took part in nine focus groups. General knowledge of risk factors for breast cancer in the community is limited, particularly in relation to modifiable factors such as alcohol consumption and postmenopausal obesity, with many women describing feelings of 'shock' following this information. Women overwhelming believed that information on modifiable risk factors for breast cancer should be communicated more widely, however communication preferences for receiving this information varied. There was a strong preference amongst the women for a cascade of information which they believed may then help target greater number of women of all ages and backgrounds. Despite worry about long-term compliance, women also supported various lifestyle interventions which may help them and other women to reduce their overall risk. CONCLUSIONS: Findings from this study highlight the need for more widespread community communication and education about risk factors for breast, in particular potentially modifiable risk factors such as alcohol consumption and postmenopausal obesity. As breast screening programs in Australia and globally begin to evaluate the potential for risk-related screening this will provide an additional context for primary prevention, hence planning of messaging and piloting of lifestyle-related prevention strategies in breast cancer is needed now. Gaining an understanding of women's preferences for communication and forms of interventions is vital to ensure their engagement.

Psychosocial impact of testing human papillomavirus positive in Australia's human papillomavirus-based cervical screening program: A cross-sectional survey.

OBJECTIVE: To examine the impact of self-reported human papillomavirus (HPV) test result (HPV negative, HPV positive, HPV result unknown) on a range of psychosocial outcomes. METHODS: Women and other people with a cervix in Australia aged 25-74 years who reported having participated in cervical screening since December 2017 were recruited through Facebook and Instagram to complete an online survey. The primary outcome measures were anxiety, emotional distress, and general distress. RESULTS: Nine hundred fifteen participants completed the online survey; 73.2% reported testing HPV negative ('HPV-'), 15% reported testing HPV positive ('HPV+') and 11.8% reported that they did not know/remember their test result ('HPV unknown'). Compared to participants testing HPV-, participants testing HPV+ had higher mean anxiety (41.67 vs. 37.08, p < 0.001) and emotional distress scores (11.88 vs. 7.71, p < 0.001). Concern about test result (34.3% vs. 1.3%, p < 0.001), perceived risk compared to average women (55.4% vs. 14.1%, p < 0.001), and cancer worry (27.8% vs. 5.9%, p < 0.001) were also greater among HPV+ participants than participants testing HPV-. Participants testing HPV+ felt less reassured about their screening result than participants testing HPV- (16% vs. 75.1%, p < 0.001). Participants testing HPV+ had greater knowledge of HPV (11.96 vs. 10.36 out of 16, p < 0.001) and HPV testing (3.94 vs 3.28 out of 5, p < 0.001) than participants who reported testing HPV-. CONCLUSIONS: Elevated levels of anxiety and emotional distress were found in those testing HPV+ compared with those testing HPV-. Future research should examine what strategies should be used to deliver test results and what additional information is provided, in order to alleviate anxiety among individuals testing HPV+.

General practitioners' views and experiences of communicating with older people about cancer screening: a qualitative study.

BACKGROUND: Older adults should be supported to make informed decisions about cancer screening. However, it is unknown how general practitioners (GPs) in Australia communicate about cancer screening with older people. AIM: To investigate GPs' views and experiences of communicating about cancer screening (breast, cervical, prostate, and bowel) with older people (≥70 years). DESIGN AND SETTING: Qualitative, semi-structured interviews, Australia. METHOD: Interviews were conducted with GPs practising in Australia (n = 28), recruited through practice-based research networks, primary health networks, social media, and email invitation. Interviews were audio-recorded and analysed thematically using Framework Analysis. RESULTS: Findings across GPs were organized into 3 themes: (i) varied motivation to initiate cancer screening discussions; some GPs reported that they only initiated screening within recommended ages (<75 years), others described initiating discussions beyond recommended ages, and some experienced older patient-initiated discussions; (ii) GPs described the role they played in providing screening information, whereby detailed discussions about the benefits/risks of prostate screening were more likely than other nationally funded screening types (breast, cervical, and bowel); however, some GPs had limited knowledge of recommendations and found it challenging to explain why screening recommendations have upper ages; (iii) GPs reported providing tailored advice and discussion based on personal patient preferences, overall health/function, risk of cancer, and previous screening. CONCLUSIONS: Strategies to support conversations between GPs and older people about the potential benefits and harms of screening in older age and rationale for upper age limits to screening programmes may be helpful. Further research in this area is needed.

Understanding women's choices for management of cervical intraepithelial neoplasia 2 (CIN2): Qualitative analysis of a randomised experimental study.

BACKGROUND: Active surveillance for cervical intraepithelial neoplasia 2 (CIN2) would allow time for most cases to regress naturally and in turn avoid potentially unnecessary and harmful treatment. AIM: To determine reasons for choosing active surveillance over surgery among women given a hypothetical diagnosis of CIN2. MATERIALS AND METHODS: Women residing in Australia aged 25-40 years with no prior diagnosis of cervical cancer, cervical abnormality CIN2 or above, and/or previous hysterectomy, were randomised to one of four identical hypothetical scenarios of testing human papillomavirus (HPV)-positive: high-grade cytology and a diagnosis of CIN2 that used alternate terminology to describe resolution of abnormal cells and/or inclusion of an overtreatment statement. Participants selected active surveillance or surgery after viewing the scenario and free-text reason/s for their choice were thematically analysed. RESULTS: Of the 1638 women randomised, 79% (n = 1293) opted for active surveillance. The most common reasons for choosing active surveillance included concerns about surgery and associated risks, preferring to 'wait and see', trusting the doctor's recommendations and having an emotional response toward surgery. For women who chose surgery, being risk-averse, addressing the issue straight away and perceiving surgery to be the better option for them were the most common themes identified. CONCLUSION: When presented with balanced information on the benefits and harms of different management options for CIN2 and given a choice, most women in this hypothetical situation chose active surveillance over surgery. Addressing women's concerns about active surveillance may open up the possibility that if deemed safe, it could be an acceptable alternative for women.

Active surveillance as a management option for cervical intraepithelial neoplasia 2: An online experimental study.

OBJECTIVE: To investigate framing of active surveillance as a management option for cervical intraepithelial neoplasia (CIN)2 in women of childbearing age. METHODS: We conducted a between-subjects factorial (2 × 2) randomised experiment. Women aged 25-40 living in Australia were presented with the same hypothetical pathway of testing human papillomavirus (HPV)-positive, high-grade cytology and a diagnosis of CIN2, through an online survey. They were randomised to one of four groups to evaluate the effects of (i) framing (method of explaining resolution of abnormal cells) and (ii) inclusion of an overtreatment statement (included versus not). Primary outcome was management choice following the scenario: active surveillance or surgery. RESULTS: 1638 women were randomised. Overall, preference for active surveillance was high (78.9%; n = 1293/1638). There was no effect of framing or providing overtreatment information, or their interaction, on management choice. After adjusting for intervention received, age, education, and other model covariates, participants were more likely to choose active surveillance over surgery if they had not already had children, had plans for children in the future, had no family history of cancer, had no history of endometriosis, had adequate health literacy, and more trust in their GP. Participants were less likely to choose active surveillance over surgery if they were more predisposed to seek health care for minor problems. CONCLUSIONS: Although we found no framing effect across the four conditions, we found a high level of preference for active surveillance with associations of increased preference that accord with the desire to minimise potential risks of CIN2 treatment on obstetric outcomes. These are valuable data for future clinical trials of active surveillance for management of CIN2 in younger women of childbearing age. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN12618002043213, 20/12/2018, prior to participant enrolment).

Awareness of the link between human papillomavirus and oral cancer in UK university students.

Awareness of the link between human papillomavirus (HPV) and oral cancer varies across populations. Levels of awareness and factors may impact HPV vaccine uptake in women and the intent to obtain the vaccine in men if it becomes available. A cross-sectional survey of 1415 UK university students (495 men and 920 women) aged 18-25 years was conducted. Women who had and had not received the HPV vaccine were included. Vaccination was not available for men at the time of the survey. Seventy percent of participants had heard of oral cancer but only 25% were aware of the link between HPV and oral cancer. Women who ever engaged in sexual activity (adjusted odds ratio, aOR = 1.74; 95% CI: 1.12-2.72) or had at least one dose of the HPV vaccine (aOR = 1.71; 95% CI: 1.24-2.37) were more likely to be aware. Men who intend to receive the HPV vaccine in the future were more likely to be aware (aOR = 1.62; 95% CI: 1.04-2.53). Non-white women were less likely to be vaccinated (aOR = 0.56; 95% CI: 0.41-0.77). However, being aware was associated with HPV vaccine uptake in women (aOR = 1.65; 95% CI: 1.19-2.28) and borderline associated with the intent to obtain the HPV vaccine in men (aOR = 1.52; 95% CI: 0.99-2.35). Non-heterosexual men were more willing than heterosexuals to receive the vaccine. Following the UK gender-neutral HPV vaccination programme, there is an opportunity to increase awareness about the link between HPV and oral cancers aside from the cervical cancer link to influence HPV vaccine uptake.

COVID-19 Misinformation Trends in Australia: Prospective Longitudinal National Survey.

BACKGROUND: Misinformation about COVID-19 is common and has been spreading rapidly across the globe through social media platforms and other information systems. Understanding what the public knows about COVID-19 and identifying beliefs based on misinformation can help shape effective public health communications to ensure efforts to reduce viral transmission are not undermined. OBJECTIVE: This study aimed to investigate the prevalence and factors associated with COVID-19 misinformation in Australia and their changes over time. METHODS: This prospective, longitudinal national survey was completed by adults (18 years and above) across April (n=4362), May (n=1882), and June (n=1369) 2020. RESULTS: Stronger agreement with misinformation was associated with younger age, male gender, lower education level, and language other than English spoken at home (P<.01 for all). After controlling for these variables, misinformation beliefs were significantly associated (P<.001) with lower levels of digital health literacy, perceived threat of COVID-19, confidence in government, and trust in scientific institutions. Analyses of specific government-identified misinformation revealed 3 clusters: prevention (associated with male gender and younger age), causation (associated with lower education level and greater social disadvantage), and cure (associated with younger age). Lower institutional trust and greater rejection of official government accounts were associated with stronger agreement with COVID-19 misinformation. CONCLUSIONS: The findings of this study highlight important gaps in communication effectiveness, which must be addressed to ensure effective COVID-19 prevention.

No longer recommended for cervical screening: How women aged 18-24 feel about the renewed National Cervical Screening Program.

BACKGROUND: Since December 2017, the Australian National Cervical Screening Program no longer recommends screening for women under 25 years of age. AIM: To explore the attitudes of women under 25 years toward the changes. METHODS: In December 2019, women aged 18-24, residing in Australia, were recruited via the social media platform Instagram and Facebook. Descriptive analysis, t-tests, χ2 tests and multivariable regressions were used to analyse the data. RESULTS: Five hundred and twelve women completed a cross-sectional web-based survey. Women who were older (22-24: 3.1 vs 18-21: 2.8, P < 0.001), sexually active (3.1 vs 2.7, P = 0.003), vaccinated against human papillomavirus (mean = 3.2 vs 2.7, P = 0.005) or who had screened previously (mean = 3.5 vs 2.8, P < 0.001) had significantly greater knowledge about the current cervical screening practices. Older women (odds ratio (OR) = 0.85, 95% CI 0.80-0.95) or those who had screened previously (OR = 0.51, 95% CI 0.31-0.83) were less positive about the delayed start age of screening and five-yearly screening (OR = 0.54, 95% CI 0.35-0.85). A significant association was determined between being sexually active (χ2 (4) = 32.71, P < 0.001) and women who had screened previously (χ2 (4) = 34.43, P < 0.001), with a greater intention to screen in the future. Regarding health information, 64.6% of women had never heard of the 'National Cervical Screening Program' website and 38.9% of the sample (n = 199/512) reported they had 'rarely' noticed any health information regarding cervical screening in the past 12 months. CONCLUSION: Further work is required to rectify women's knowledge of cervical screening to ensure women under 25 are aware of the screening guidelines and reduce the potential for over-testing and overtreatment in this age group.

Australian National Cervical Screening Program renewal: Attitudes and experiences of general practitioners, and obstetricians and gynaecologists.

BACKGROUND: In 2017, the Australian National Cervical Screening Program (NCSP) implemented five-yearly primary human papillomavirus (HPV) screening for women aged 25-74. It is important that clinicians are able to explain the NCSP changes to women and confidently address concerns. AIMS: This study examined Australian clinicians' attitudes toward and experiences of the NCSP renewal since its implementation. MATERIALS AND METHODS: Cross-sectional survey of clinicians (general practitioners, obstetricians and gynaecologists) involved in cervical screening, distributed two years after implementation of the renewed NCSP. Responses were analysed using descriptive statistics and thematic analysis. RESULTS: Six hundred and seven participants completed the survey. More than 80% of clinicians were comfortable with the main NCSP changes: extended screening intervals, increased age of first screening, and screening test used. However, only 47% of clinicians reported having utilised the National Cancer Screening Register, and a third of clinicians did not believe that self-collection was a reasonable alternative to practitioner-collected screening for under-screened women. Increased demands for colposcopy were reported. All clinicians identified at least one area of educational need, including the management of women with a history of screen-detected abnormalities in the previous program (34.9%), post-colposcopy management for women with no abnormalities detected (25.5%), and screening in complex scenarios (eg immunocompromise) (26.5%). CONCLUSIONS: Overall, Australian clinicians are comfortable with the main changes to the cervical screening program. Certain areas may require further policy review, such as screening in complex clinical scenarios, colposcopy availability, accessibility of the Register and self-collection. These issues could be meaningful for other countries switching to HPV-based screening.

Understanding overuse of diagnostic imaging for patients with low back pain in the Emergency Department: a qualitative study.

BACKGROUND: Overuse of lumbar imaging in the Emergency Department is a well-recognised healthcare challenge. Studies to date have not provided robust evidence that available interventions can reduce overuse. For an intervention aimed at reducing imaging to be effective, insight into how both patients and clinicians view lumbar imaging tests is essential. AIM: To explore factors that might influence overuse of lumbar imaging in the Emergency Department. METHODS: Participants were recruited from three hospitals in Sydney, Australia between April and August 2019. We conducted focus groups and/or interviews with 14 patients and 12 clinicians. Sessions were audio-recorded and transcribed verbatim. Data were analysed using framework analysis by a team of four researchers with diverse backgrounds. RESULTS: Patients described feeling that the decision about lumbar imaging was made by their Emergency Department clinician and reported little involvement in the decision-making process. Other potential drivers of lumbar imaging overuse from the patients' perspective were strong expectations for lumbar imaging, a reluctance to delay receiving a diagnosis, and requirements from third parties (eg, insurance companies) to have imaging. Emergency Department clinicians suggested that the absence of an ongoing therapeutic relationship, and the inability to manage perceived patient pressure could drive overuse of lumbar imaging. Suggested protective factors included: involving patients in the decision, ensuring clinicians have the ability to explain the reasons to avoid imaging and collaborative approaches to care both within the Emergency Department and with primary care. CONCLUSION AND KEY FINDINGS: We found several factors that could contribute to overuse of lumbar imaging in the Emergency Department. Solutions to overuse of lumbar imaging in the Emergency Department could include: (1) strategies to involve patients in decisions about imaging; (2) training and support to provide thorough and well explained clinical assessment for low back pain; and (3) systems that support collaborative approaches to care.

Web-Based Health Information Following the Renewal of the Cervical Screening Program in Australia: Evaluation of Readability, Understandability, and Credibility.

BACKGROUND: Three main changes were implemented in the Australian National Cervical Screening Program (NCSP) in December 2017: an increase in the recommended age to start screening, extended screening intervals, and change from the Papanicolaou (Pap) test to primary human papillomavirus screening (cervical screening test). The internet is a readily accessible source of information to explain the reasons for these changes to the public. It is important that web-based health information about changes to national screening programs is accessible and understandable for the general population. OBJECTIVE: This study aimed to evaluate Australian web-based resources that provide information about the changes to the cervical screening program. METHODS: The term cervical screening was searched in 3 search engines. The first 10 relevant results across the first 3 pages of each search engine were selected. Overall, 2 authors independently evaluated each website for readability (Flesch Reading Ease [FRE], Flesch-Kincaid Grade Level, and Simple Measure of Gobbledygook [SMOG] index), quality of information (Patient Education Materials Assessment Tool [PEMAT] for printable materials), credibility (Journal of the American Medical Association [JAMA] benchmark criteria and presence of Health on the Net Foundation code of conduct [HONcode] certification), website design, and usability with 5 simulation questions to assess the relevance of information. A descriptive analysis was conducted for the readability measures, PEMAT, and the JAMA benchmark criteria. RESULTS: Of the 49 websites identified in the search, 15 were eligible for inclusion. The consumer-focused websites were classed as fairly difficult to read (mean FRE score 51.8, SD 13.3). The highest FRE score (easiest to read) was 70.4 (Cancer Council Australia Cervical Screening Consumer Site), and the lowest FRE score (most difficult to read) was 33.0 (NCSP Clinical Guidelines). A total of 9 consumer-focused websites and 4 health care provider-focused websites met the recommended threshold (sixth to eighth grade; SMOG index) for readability. The mean PEMAT understandability scores were 87.7% (SD 6.0%) for consumer-focused websites and 64.9% (SD 13.8%) for health care provider-focused websites. The mean actionability scores were 58.1% (SD 19.1%) for consumer-focused websites and 36.7% (SD 11.0%) for health care provider-focused websites. Moreover, 9 consumer-focused and 3 health care provider-focused websites scored above 70% for understandability, and 2 consumer-focused websites had an actionability score above 70%. A total of 3 websites met all 4 of the JAMA benchmark criteria, and 2 websites displayed the HONcode. CONCLUSIONS: It is important for women to have access to information that is at an appropriate reading level to better understand the implications of the changes to the cervical screening program. These findings can help health care providers direct their patients toward websites that provide information on cervical screening that is written at accessible reading levels and has high understandability.

Implementing changes to cervical screening: A qualitative study with health professionals.

BACKGROUND: Profound changes were made to the Australian National Cervical Screening Program in December 2017, which included a reduction in the frequency of screening and a new cervical screening test. AIM: To explore the attitudes and experiences of health professionals practising in Australia since implementation of these changes. MATERIALS AND METHODS: Thirty-one semi-structured interviews were conducted with general practitioners, obstetricians and gynaecologists, pathologists and nurses involved in cervical screening Australia-wide. Data were analysed using Framework Analysis. RESULTS: Overall, health professionals had positive attitudes toward the changes but described many challenges associated with their implementation. Participants discussed practical system challenges, communication and education, finding ways around the guidelines and other perceived 'collateral'. Practical system challenges included increased colposcopy referrals, limited access to the National Cancer Screening Register, a complex primary screening approach, and issues with self-collection. In terms of communication and education, limited public education was recognised, in addition to challenges with particular age groups of women. Finding ways around the guidelines were described, for example over-referring women for co-testing by stating symptoms, which could lead to overtreatment. Other perceived collateral were demonstrated through reduced opportunistic screening opportunities due to less frequent primary care presentations, and concern over the potential for further underscreening in already under-screened populations. CONCLUSIONS: These findings provide insight into the challenges health professionals face with renewing programs, in terms of practical issues and unexpected downstream effects which need to be addressed to ensure future implementation of the program is streamlined.

Psychosocial impact of human papillomavirus-related head and neck cancer on patients and their partners: A qualitative interview study.

OBJECTIVE: Increasing numbers of patients face the psychosocial challenge of a diagnosis of oropharyngeal squamous cell carcinoma (OSCC) caused by human papillomavirus (HPV). We explored the psychosocial impact of an HPV-OSCC diagnosis for patients and their partners. METHODS: In-depth interviews were conducted with patients (n = 20) and a subset of their partners (n = 12), identified through medical records at two UK hospitals. Interviews were recorded, transcribed verbatim and analysed using thematic Framework Analysis. RESULTS: Only 12/20 patients interviewed (and five partners) were aware of their HPV status and the main analysis focused on this sub-sample. In discussing the cause of their cancer, patients and their partners talked about not wanting to know; whether they disclosed the cause of their cancer to others; their reactions to being diagnosed with HPV; the prognosis information they were given and the questions they had about HPV. Most concerns were cancer-related rather than HPV-related, but some patients (n = 3) described feelings of embarrassment and perceived stigma about HPV. CONCLUSION: Some patients and partners who are told HPV is the cause of their OSCC have questions about HPV and seek further information. Concerns and uncertainties about the sexually transmitted nature of HPV need to be addressed by health professionals.

Understanding middle-aged and older adults' first associations with the word "cancer": A mixed methods study in England.

OBJECTIVE: Cancer is still widely feared and often associated with death. Fatalistic beliefs adversely affect help-seeking for cancer symptoms and engagement in cancer prevention. This study aims to understand middle-aged and older adults' first association with the word "cancer" and their relationship with sociodemographic factors, cancer fear, and cancer information avoidance. METHODS: We conducted a cross-sectional survey of 1464 community-based adults aged 50 to 70 living in England in April 2015. First associations with cancer were measured qualitatively and analysed using content analysis. We used binary logistic regression to analyse associations between the most common first association of cancer and sociodemographic characteristics, cancer fear, and cancer information avoidance. RESULTS: Cancer was most commonly associated with "death" (26%). Respondents with lower levels of education, living in the Midlands or North of England where cancer mortality is higher, or with close friends or family members with a cancer history, were more likely to associate cancer with death. Cancer fear was significantly associated with death associations, but cancer information avoidance was not. CONCLUSIONS: Despite improved cancer outcomes, middle-aged and older adults often associate cancer with death. Further efforts to decrease fatalistic associations in this age group may be needed.