Agreement between HADS classifications and single-item screening questions for anxiety and depression: a cross-sectional survey of cancer patients.

BACKGROUND: We assessed agreement between reported anxiety and depression levels of cancer patients using (i) single self-report items and (ii) the Hospital Anxiety and Depression Scale (HADS). We also explored whether anxiety and depression assessment by (i) single self-report items or (ii) the HADS was most strongly associated with a preference to be offered professional assistance. The proportion of patients indicating that they would accept (or were currently using) professional support if they were experiencing anxiety or depression was also examined. PATIENTS AND METHODS: A consecutive sample of cancer patients undergoing radiotherapy at four metropolitan public hospitals in Australia completed a touch screen computer survey. A consecutive subsample of patients attending three of these treatment centres answered additional questions about psychological support preferences. RESULTS: Of 304 respondents, 54% [95% confidence interval (CI) 48% to 60%] perceived that they were currently experiencing mild to severe anxiety and depression. 22% (95% CI 18% to 27%) indicated a preference to be offered professional help. There was moderate agreement between the HADS and single-item responses for categorisation of anxiety and depression. Patient-perceived mild to severe anxiety and depression levels appeared to be the best measure for identifying those with a preference to be offered professional assistance. Of a subsample of 193 respondents, 89% (95% CI 84% to 93%) indicated that if they were experiencing anxiety or depression, they would accept (or were currently using) professional support. CONCLUSIONS: Single-item screening in a cancer care setting may not adequately capture clinical anxiety and depression. However, single-items assessing patients' perceived levels of anxiety and depression are useful indicators of whether patients want to be offered, and are likely to accept, psychosocial care.

Psychological distress in cancer patients undergoing radiation therapy treatment.

PURPOSE: The objective of this study was to examine the likely presence of, and factors associated with, anxiety, depression and overall psychological distress in cancer outpatients undergoing radiation therapy treatment in Sydney, Australia. METHODS: A touchscreen computer survey was conducted in four radiation therapy treatment centre waiting rooms. Patients waiting to receive treatment completed the survey which included questions about demographic and disease characteristics, survey acceptability and the Hospital Anxiety and Depression Scale (HADS). RESULTS: A total of 454 patients (70 %) completed the touchscreen computer survey. The likely presence of anxiety (HADS-A ≥11), depression (HADS-D ≥11) and overall psychological distress (HADS-T ≥15) was 15, 5.7 and 22 %, respectively. Cancer type was found to be associated with each HADS screening category. The majority of patients reported high survey acceptability and willingness to complete similar touchscreen computer surveys in the treatment centre waiting room on additional occasions. CONCLUSIONS: As radiotherapy patients frequently attend the radiation oncology department, routine screening and intervention for elevated levels of psychological distress in this setting appears to be feasible. High survey completion rates and high patient-rated acceptability support this approach to screening. The likely presence of psychological distress is reported for this sample; however, the selection of HADS threshold scores is likely to have influenced the reported rates. Further research is needed to identify how cancer type impacts on likely caseness across the different HADS classifications examined.

Current state of medical-advice-seeking behaviour for symptoms of colorectal cancer: determinants of failure and delay in medical consultation.

AIM: There are few data on the factors associated with healthcare-seeking behaviour for symptoms of colorectal cancer. This study describes the determinants of failure and delay in seeking medical advice for rectal bleeding and change in bowel habit. METHOD: In total, 1592 persons (56-88 years) were randomly selected from the Hunter Community Study and mailed a questionnaire. RESULTS: In all, 18% (60/332) of respondents experiencing rectal bleeding and 20% (39/195) reporting change in bowel habit had never consulted a doctor. The rate of delay (>1 month) for each symptom was 18% and 37%. The reasons for delay included the assumption that the symptoms were not serious or that they were benign. Triggers for seeking medical advice varied. Healthcare-seeking behaviour for rectal bleeding had not significantly improved compared with a previous community-based study. CONCLUSION: The seriousness of symptoms, importance of early detection and prompt medical consultation must be articulated in health messages to at-risk persons.

Cancer patients' willingness to answer survey questions about life expectancy.

PURPOSE: This study aimed to determine the proportion and characteristics of radiation oncology outpatients who were willing to answer questions about their life expectancy. METHODS: A cross-sectional patient self-report survey was conducted using touch screen computers in Australian radiation oncology treatment centers. The primary outcome was the respondent's willingness to complete a survey subsection about life expectancy. Demographic and disease characteristics were also collected, and level of anxiety and depression was assessed using the Hospital Anxiety and Depression Scale. RESULTS: Of the 469 oncology outpatients who completed the survey, 327 (70 %; 95 % CI, 65 %, 74 %) indicated that they were willing to answer questions about life expectancy. Being female (p < 0.001), older (p < 0.05), born in Asia (p < 0.05), and being diagnosed with cancer types other than breast and prostate cancer (p < 0.01) were associated with lower odds of answering life expectancy questions. CONCLUSIONS: The opportunity to opt-out of survey questions about sensitive issues such as life expectancy is a feasible method for accessing important information about patient preferences while minimizing burden. Further research may be needed to improve acceptability of life expectancy research to some patient groups.

Patient or treatment centre? Where are efforts invested to improve cancer patients' psychosocial outcomes?

The psychosocial outcomes of cancer patients may be influenced by individual-level, social and treatment centre predictors. This paper aimed to examine the extent to which individual, social and treatment centre variables have been examined as predictors or targets of intervention for psychosocial outcomes of cancer patients. Medline was searched to find studies in which the psychological outcomes of cancer patient were primary variables. Papers published in English between 1999 and 2009 that reported primary data relevant to psychosocial outcomes for cancer patients were included, with 20% randomly selected for further coding. Descriptive studies were coded for inclusion of individual, social or treatment centre variables. Intervention studies were coded to determine if the unit of intervention was the individual patient, social unit or treatment centre. After random sampling, 412 publications meeting the inclusion criteria were identified, 169 were descriptive and 243 interventions. Of the descriptive papers 95.0% included individual predictors, and 5.0% social predictors. None of the descriptive papers examined treatment centre variables as predictors of psychosocial outcomes. Similarly, none of the interventions evaluated the effectiveness of treatment centre interventions for improving psychosocial outcomes. Potential reasons for the overwhelming dominance of individual predictors and individual-focused interventions in psychosocial literature are discussed.

The prevalence and characteristics of alcohol-related presentations to emergency departments in rural Australia.

BACKGROUND: The burden of harm associated with alcohol misuse is disproportionately high in rural areas of Australia, and a considerable proportion of this burden is borne by the health system. The health impact of alcohol in rural areas has been measured in terms of the contribution of alcohol to hospital inpatient admissions and mortality rates, despite many more alcohol-related cases presenting to emergency departments (EDs). This study aims to estimate the proportion of presentations to EDs in rural Australia that are alcohol-related and to identify the associated patient and presentation characteristics. METHODS: Patients aged ≥14 years presenting to four EDs in rural NSW were assessed on two measures: (1) Clinician judgement of alcohol consumption, and (2) patient self-report of alcohol consumption in the 6 h preceding the onset of their condition. RESULTS: Preliminary analyses revealed sample selection biases in two of the EDs, and these samples were consequently excluded from further analyses. In the two remaining EDs, 46% of presentations were assessed, of which 9% were identified as alcohol-related. Presentations for mental disorders, those with more urgent triage categories and those occurring on weekends or at night were more often alcohol-related. CONCLUSIONS: The prevalence of alcohol-related ED presentations observed was at the lower end of the documented range, probably due to methodological differences and limitations, as well as geographic variation. Despite this, alcohol-related presentations were associated with a substantial impact on the ED. Policies and programs to reduce the impact of alcohol on rural emergency departments are needed.

Health inequities: the need for action by schools of medicine.

BACKGROUND: It is well recognised that marked inequalities in mortality and morbidity exist between populations particularly those in lower socio-economic groups, including Indigenous and some ethnic minorities. Academic medicine has not yet articulated a clear stance on reducing health inequity within communities. AIM: To develop criteria that medical schools can implement to reduce health inequity. These criteria will enable the performance of a medical school's commitment to health equity to be measured. RESULTS AND CONCLUSION: We suggest that the contribution to lessening health inequity should be seen as an integral and important role of undergraduate medical education and the academic institutions that provide such programs. Five strategies aimed at increasing the commitment of medical and other undergraduate health students to work with disadvantaged groups to improve their health are described. They include student selection to increase representativeness of students and importantly, support for retention and academic success; undergraduate curriculum, both core and elective, to address inequality and provide skills necessary to implement change in a range of areas that impact on health; academic physicians modelling the above by actively working in and for disadvantaged groups; developing centres of excellence carrying out research in health inequity, particularly intervention rather than solely descriptive research and creating high status academic appointments in key designated positions addressing inequity. Schools of Medicine could be rated on their action on these criteria so that benchmarking across institutions could occur.

Breaking bad news: consensus guidelines for medical practitioners.

PURPOSE AND DESIGN: One of the more difficult tasks that clinicians must perform as part of their care of patients is that of conveying bad news, such as a severe diagnosis or death. However, there is a paucity of empirically founded information that relates to the specific steps for breaking bad news. We report on a set of guidelines for breaking bad news that was developed using a consensus process and incorporates the views of medical oncologists, general practitioners, surgeons, nurse consultants, social workers, clergy, human rights representatives, cancer patients, hospital interns, and clinical directors of medical schools in Australia. RESULTS AND CONCLUSION: It is recommended that further research be undertaken in a number of areas. First, there is a need to assess patients' versus providers' perceptions of the importance of each of the steps in breaking bad news, in order to define criteria for minimal levels of competence in this area. Second, controlled trials are needed to assess the effectiveness of the guidelines in changing clinical practice, and to identify the most effective strategies for breaking bad news to patients.

Measuring quality of life in cancer patients.

The diagnosis and management of cancer can have a major impact on every aspect of a patient's quality of life. Despite its importance, quality of life is rarely a reported outcome in randomized clinical trials in cancer patients. Failure to collect quality-of-life information may reflect a lack of information among researchers and clinicians about the adequacy and relative merits of measures available for assessing quality of life. We reviewed the adequacy of the 17 existing scales for assessing quality of life in cancer patients against characteristics needed for an adequate measure. None of the existing measures met all of the criteria. Recommendations about the relative adequacy of existing scales were made.

Interventions in preschools to increase the use of safety restraints by preschool children.

Despite the proven safety value of wearing vehicle safety restraints, people continue to travel without this protection. Legislation requiring the use of safety restraints has been implemented in several countries, including Australia, in an attempt to improve rates of restraint use. In Australia, legislation dramatically increased rates of adult restraint use, yet the rate of restraint use by children remains comparatively low. One of the main reasons for parents not restraining their child is the child's dislike of wearing a restraint, with resultant disruptive behavior. This study compared two interventions implemented within preschools: a coercive intervention aimed at parents and an educational intervention aimed at preschool children. Measures of restraint use were made by direct observation at preschools prior to intervention and again immediately following the 2-week interventions. The safety restraint use of children in the control and coercive intervention groups did not change significantly as a result of intervention. Restraint use of children in the educational intervention group increased 15 percentage points from 60.6% to 75.0%: a significant increase of 25%. This novel intervention approach holds promise as a means of increasing preschool children's use of safety restraints.

Adaptation and validation of the SF-36 Health Survey for use in Australia.

This article reports on the process undertaken to adapt the U.S. version of the SF-36 to an Australian setting. In addition, the results of psychometric testing, using the International Quality of Life Assessment (IQOLA) Project process and standards, is also reported. The adaptation process involved a number of steps including: a series of forward and backward translations; ratings of the difficulty of translating the SF-36 and the quality of the resulting translation. To assess the psychometric properties of the Australian form, a random sample of people residing in the Hunter region of New South Wales, Australia, were invited to complete the SF-36 with 855 respondents consenting to complete the measure. Principal components analyses supported the assumption of two factors underlying the measure with the percentage of variance explained by these factors ranging from between 0.66 and 0.77. Demonstrable internal consistency (both item and scale) and test-retest reliability were also found.

An examination of self- and telephone-administered modes of administration for the Australian SF-36.

The impact of administration mode on health-related quality of life measurement instruments has received little attention, especially for the SF-36. General community members were randomly selected to complete the Australian version of the SF-36 Health Survey using either telephone or mail modes. Modes were compared across a number of indices: data collection costs; consent rates and non-consent bias; data quality (completeness of data and internal consistency reliability); and response effects. Data collection costs were lower for the telephone mode. A significantly higher consent rate was achieved with the telephone mode. Those who were younger were more likely to refuse to participate when the mail mode was adopted, while older people were more likely not to consent to the telephone mode. The rate of missing responses was higher for the mail mode, while significant differences were found between modes in internal consistency reliability estimates. Health ratings were more favorable for the telephone administration. The results are discussed in light of the advantages and disadvantages of each administration mode.

Testing the equivalence of translations of widely used response choice labels: results from the IQOLA Project. International Quality of Life Assessment.

The similarity in meaning assigned to response choice labels from the SF-36 Health Survey (SF-36) was evaluated across countries. Convenience samples of judges (range, 10 to 117; median = 48) from 13 countries rated translations of response choice labels, using a variation of the Thurstone method of equal appearing intervals. Judges marked a point on a 10-cm line-representing the magnitude of a response choice label (e.g., "good" relative to the anchors of "poor" and "excellent"). Ratings were evaluated to determine the ordinal consistency of response choice labels within a response scale; the degree to which differences between adjacent response choice labels were equal interval; and the amount of variance due to response choice label, country, judge, and interaction between response choice label and country. Results confirmed the hypothesized ordering of response choice labels; the percentage of ordinal pairs ranged from 88.7% to 100% (median = 98.2%) across countries and response scales. Examination of the average magnitudes of response choice labels supported the "quasi-interval" nature of the scales. Analysis of variance (ANOVA) results supported the generalizability of response choice magnitudes across countries; labels explained 64% to 77% of the variance in ratings, and country explained 1% to 3%. These results support the equivalence of SF-36 response choice labels across countries. Departures from the assumption of equal intervals, when observed, were similar across countries and were greatest for the two response scales that are recalibrated under standard SF-36 scoring. Results provide justification for scoring translations of individual items using standard SF-36 scoring; whether these items form the same scales in other countries as they do in the United States is evaluated with tests of scaling assumptions.

Compliance in the treatment of hypertension. A need for action.

Compliance is commonly defined as the extent to which a person's behavior coincides with medical or health advice. There is evidence that noncompliance is a common problem with many medications, including antihypertensive treatment. Since noncompliance can have serious adverse effects on patient health it is important that practitioners make use of available strategies for increasing compliance. This paper considers aspects of the literature concerning noncompliance with antihypertensive medications and presents a number of strategies that practitioners can use to increase compliance. These include strategies for increasing patient recall of information and for implementing reminder systems. There is some evidence that eliciting social support can aid compliance as can presenting information about side effects. The importance of prescribing the simplest possible dosage regimen is emphasized.

Increasing women's compliance with opportunistic cervical cancer screening: a randomized trial.

Our objective was to evaluate the efficacy and acceptability of two interventions designed to increase opportunistic cervical cancer screening. We designed a randomized trial of two interventions additional to usual care. We recruited 17 male general practitioners selected at random from the inner metropolitan region of Sydney, Australia. The patients were 202 women, between 20 and 65 years of age, eligible for a Pap smear. We allocated minimal and maximal interactional interventions to obtain consent for a Pap smear. Our main outcome measure was women's having a Pap smear during the consultation or within one month. We also measured acceptability of interventions to practitioners and women. These were our results: minimal: 55% of women had a Pap smear; maximal: 67% of women had a Pap smear; total when both approaches are combined: 61%. We conclude that brief advice is as effective as maximal persuasion in increasing women's compliance with opportunistic screening in routine consultations. Both interventions were acceptable to women. Practitioners preferred the minimal intervention. We demonstrate opportunistic screening is an effective and acceptable way to encourage women at risk to have a Pap smear.

The accuracy of self-reported health behaviors and risk factors relating to cancer and cardiovascular disease in the general population: a critical review.

OBJECTIVE: To critically review the literature concerning the accuracy of self-reported health behaviors and risk factors relating to cancer and cardiovascular disease among the general population. METHOD: A literature search was conducted on three major health research databases: MEDLINE, HealthPLAN, and PsychLit. The bibliographies of located articles were also checked for additional relevant references. Studies meeting the following five inclusion criteria were included in the review: They were investigating the accuracy of self-report among the general population, as opposed to among clinical populations. They employed an adequate and appropriate gold standard. At least 70% of respondents consented to validation, where validation imposed minimal demands on the respondent; and 60% consent to validation was considered acceptable where validation imposed a greater burden. They had a sample size capable of estimating sensitivity and specificity rates with 95% confidence intervals of width +/-10%. The time lag between collection of the self-report and validation data for physical measures did not exceed one month. RESULTS: Twenty-four of 66 identified studies met all the inclusion criteria described above. In the vast majority, self-report data consistently underestimated the proportion of individuals considered "at-risk." Similarly, community prevalences of risk factors were considerably higher according to gold standard data sources than they were according to self-report data. CONCLUSIONS: This review casts serious doubts on the wisdom of relying exclusively on self-reported health information. It suggests that caution should be exercised both when trying to identify at-risk individuals and when estimating the prevalence of risk factors among the general population. The review also suggests a number of ways in which the accuracy of individuals' self-reported health information can be maximized.

Community action for health promotion: a review of methods and outcomes 1990-1995.

OBJECTIVE: Our objective was to explore the effectiveness of community action as a strategy for health promotion, through a critical review of five years of community action evaluation literature. METHODS: Community action was defined as a health promotion, program that involved the community in implementation and control of the process of the program. Criteria for scientific evaluation of programs were proposed for sampling and control procedures, reliability and validity of instruments, analysis techniques, and specification of details of the intervention. A critical review of the literature, located by an on-line and related reference search, was undertaken for community action aimed at reducing cancer and cardiovascular disease, between January 1990 and May 1995. RESULTS: None of seven community action studies (17 articles) that examined cancer risk factors fulfilled all the criteria for rigorous scientific evaluation. The most methodologically adequate cancer study, the COMMIT intervention, had only a moderate degree of success in reducing community smoking rates. Similarly, none of the six studies (25 articles) on cardiovascular disease fulfilled all the criteria. The results for the most methodologically adequate study, the Minnesota Heart Health Program, were disappointing, with strong secular trends preventing adequate assessment of the intervention effect. CONCLUSIONS: The finding that none of the reviewed studies met all evaluation criteria was due to several factors, including political considerations, feasibility, and the continued evolution of the science of evaluation in health promotion. Some important questions are posed for researchers by the failure of methodologically superior projects, such as COMMIT, to show major gains in reducing health risk behaviors.

A community study of delay in presenting with signs of melanoma to medical practitioners.

In the absence of more effective treatment for advanced tumors, early diagnosis and treatment of localized tumors is the most effective way of reducing the burden of illness associated with melanoma. This study examined the following factors: prevalence of signs of melanoma (a mole changing in size, shape, appearance, or color, itching or tingling, bleeding or weeping, becoming raised) in 1344 individuals in a randomly selected sample of 1075 households; the length of delay in seeking medical advice; the factors associated with either going to a medical practitioner or not going/delaying; and the actions of the medical practitioners when first presented with these signs. The results indicate that a large proportion of the sample (11.9%, n = 156) had observed signs of melanoma in the previous 12 months. Of the sample reporting signs that had first appeared in the previous 5 years, only 32% sought medical advice about the signs within the recommended period. Of the sample either not seeking advice at all or delaying, 49% reported that they thought the sign "wasn't serious/would clear up." Furthermore, 30% of the sample either did not known or underrated the importance of early detection and treatment of lesions. These results indicate that there is a deficit in the knowledge of the general public about the signs of melanoma, the severity of the disease, and the possible risks associated with delay.

Behavioural alcohol research: new directions or more of the same?

AIM: Despite a large body of literature, a substantial burden of illness related to the abuse of alcohol, as well as significant economic and social costs, persist. As such, a critical examination of the type of research being published in relation to alcohol misuse seems appropriate, particularly since some experts in the field have expressed the view that the current distribution of research types may not be optimal. FINDINGS: The types of research conducted in two separate years, 1983 and 1993, were examined critically. Generally, the types of research conducted in both years was found to be similar: the majority of published alcohol research is behavioural, the majority of published behavioural alcohol research is descriptive and the majority of published behavioural intervention alcohol research represents tertiary prevention studies. Although the reasons for this distribution of research types are undoubtedly numerous and complex, some possible explanations are discussed. CONCLUSIONS: Overall, it is concluded that the current approach to alcohol research may have engendered a distribution of research types which is somewhat less than ideal and that, as such, a new approach may be indicated. Some strategies that may assist in redressing the perceived imbalance are considered.

General practitioners' role in preventive medicine: scenario analysis using smoking as a case study.

AIM: It is the purpose of this paper to develop a model which may be used in conjunction with scenario analysis to evaluate strategies which are available to assist the general practitioner (GP) in reducing smoking behaviour among their patients. DESIGN: The scenario analysis uses a four-step procedure which involves identifying opportunities for detection, intervention and efficacy, and assigning probabilities to outcome to enable a range of prevention strategies to be examined in both isolation and in combination. SETTING AND PARTICIPANTS: This study deals specifically with Australian general practice and the model is derived by using information for a smoker visiting their GP within a 6-month period together with empirical evidence on the rates of detection, intervention and efficacy. MEASUREMENTS: The outcome measures, which are evaluated in terms of marginal effectiveness, include the number of smoking patients detected, the number of smoking patients offered an intervention, the number of smoker patients who quit as a result of the intervention and the additional years of life saved due to an intervention. FINDINGS. The most significant indicator for reducing smoking rates among patients is improving the efficacy of interventions. The results also suggest that although improvements in the rate of GP detection of patients' smoking status have a potentially greater effect on quit rates than increasing intervention levels, increasing both detection and intervention levels had a greater effect than each strategy alone. DISCUSSION: : General practitioners have an important role to play in preventive medicine. The knowledge, skill and attitude of practitioners toward smoking are significant, and they can be the prime motivators is persuading their patients to stop smoking. Detection, intervention and efficacious strategies are all key elements in achieving this result.