Challenges to uptake of cancer education resources by rural Aboriginal Health Workers: the Cancer Healing Messages flipchart experience.

INTRODUCTION: The Australian Aboriginal and Torres Strait Islander (Aboriginal) population has a higher age-standardised cancer mortality rate and a significantly lower 5-year survival rate for all cancers than the non-Aboriginal population. Aboriginal people from regional and remote South Australia and the Northern Territory, are often required to travel to Adelaide to access specialist cancer care services. The burden and expenses associated with transport and accommodation and cultural and linguistic factors have been identified as barriers to accessing medical treatment and health services. In collaboration with community and stakeholders, Cancer Council South Australia led the development of the Cancer Healing Messages flipchart and patient flyer to assist health professionals in explaining cancer and the cancer journey to Aboriginal cancer patients and their families. This study examined the usage, acceptability and perceived usefulness of the resources, barriers to uptake, and strategies to improve their utilisation and sustainability. METHODS: An evaluation survey was conducted among Aboriginal Health Workers (AHWs) and other health professionals working with Aboriginal clients in South Australia (n=18). Participants indicated whether they agreed that the resources are valuable, culturally appropriate, helpful for explaining aspects of cancer to Aboriginal cancer patients, and useful with regard patient outcomes, how frequently they used or would use the resources for information, and how they use the flipchart in practice. Participants were also asked to report any usage barriers. RESULTS: The resources were considered useful, valuable and culturally appropriate by almost all participants; however, there was a discrepancy between intentions to use the resources and actual uptake, which was low. The most commonly reported barriers related to appropriateness for certain patients and lack of availability of resources in some contexts. CONCLUSION: The Cancer Healing Messages flipchart and patient flyer are perceived as appropriate, valuable, and useful tools for AHWs. A long-term strategy and clear implementation plan involving education, training and promotion of the materials, is required to achieve broad reach and sustainable utilisation of the Cancer Healing Messages flipchart and patient flyer.

Exploring organisational readiness to implement a preventive intervention in Australian general practice for overweight and obese patients: key learnings from the HeLP-GP trial.

BACKGROUND: The HeLP-GP trial aimed to increase the capacity of practice nurses to deliver weight management to overweight and obese patients through an intervention comprising a health check, a lifestyle app and/or telephone coaching. This paper describes implementation through the lens of organisational readiness with emphasis on the role of the practice nurse. METHODS: Routinely collected mixed method research data including practice surveys, field notes, and diaries and process data were mapped against the domains: motivation to implement, general capacity and intervention-specific capacity. RESULTS: Organisational readiness varied considerably, particularly the domain of intervention-specific capacity. Practice nurse turnover negatively impacted the implementation, affecting half of the practices. We observed a general lack of practice-based support for intervention delivery, and varying levels of interest, skill and confidence in delivering the intervention. Nurses struggled to complete the research and intervention tasks in a timely way. Conducting risk assessments and referring to coaching were generally not problematic; however, we noted lower confidence levels with the lifestyle app and instructing patients to use it. CONCLUSIONS: We found a lack of general 'readiness' inherent in the nursing role, particularly related to their capacity to complete intervention tasks and practice-level support to implement the intervention. For nurses in general practice to fulfil their potential in supporting patients to reduce risk and adopt healthier life choices, our study indicates that more could be done to improve their workforce positioning and remuneration, which may, in turn, improve continuity of care, retention and individual motivation.

In it for the long haul: the complexities of managing overweight in family practice: qualitative thematic analysis from the Health eLiteracy for Prevention in General Practice (HeLP-GP) trial.

BACKGROUND: Australia has one of the highest rates of overweight and obesity in the developed world, and this increasing prevalence and associated chronic disease morbidity reinforces the importance of understanding the attitudes, views, and experiences of patients and health providers towards weight management interventions and programs. The purpose of this study was to investigate patients, family practitioners and family practice nurses' perceptions and views regarding the receipt or delivery of weight management within the context of the HeLP-GP intervention. METHODS: A nested qualitative study design including semi-structured interviews with family practitioners (n = 8), family practice nurses (n = 4), and patients (n = 25) attending family practices in New South Wales (n = 2) and South Australia (n = 2). The patient interviews sought specific feedback about each aspect of the intervention and the provider interviews sought to elicit their understanding and opinions of the strategies underpinning the intervention as well as general perceptions about providing weight management to their patients. Interviews were recorded and transcribed verbatim, and coding and management conducted using NVivo 12 Pro. We analysed the interview data using thematic analysis. RESULTS: Our study identified three key themes: long-term trusting and supportive relationships (being 'in it for the long haul'); initiating conversations and understanding motivations; and ensuring access to multi-modal weight management options that acknowledge differing levels of health literacy. The three themes infer that weight management in family practice with patients who are overweight or obese is challenged by the complexity of the task and the perceived motivation of patients. It needs to be facilitated by positive open communication and programs tailored to patient needs, preferences, and health literacy to be successful. CONCLUSIONS: Providing positive weight management in family practice requires ongoing commitment and an open and trusting therapeutic relationship between providers and patients. Behaviour change can be achieved through timely and considered interactions that target individual preferences, are tailored to health literacy, and are consistent and positive in their messaging. Ongoing support of family practices is required through funding and policy changes and additional avenues for referral and adjunctive interventions are required to provide comprehensive weight management within this setting.

A 'plethora of services' but a lack of consistency: A qualitative study of service providers' perspectives about transitioning from hospital to home for older South Australians.

OBJECTIVE: We explored the perspectives of professionals working in health and aged care services in South Australia about factors that influenced successful transitions from hospital to home or residential aged care home for older people. We examined successful and recommended strategies that could support safe transitions following hospital discharge and reduce avoidable hospital admissions in South Australia. METHODS: Nineteen professionals from acute, post-acute, primary, community and aged care settings in South Australia participated in semi-structured interviews. Qualitative content analysis was conducted. RESULTS: Participants reported that navigating service provision could be difficult, compounded by different funding arrangements for hospitals, community, primary care and aged care services. Some participants felt that there was an over-reliance on the hospital sector, leaving primary care and community-based services under-utilised to support hospital transitions. The importance of good communication between services and sectors was highlighted. Participants described different categories of services that supported safe transitions by supporting older people immediately post-discharge; services that provided support to stay at home in the weeks and months following discharge; and services that helped the person receive health care at locations other than hospitals or emergency departments when they were unwell. Participants noted that successful programs were not always maintained. CONCLUSIONS: Division of responsibility of aged and health-care services between state and national governance contributes to fragmentation of care in South Australia. Careful planning of transitions and coordination of services across sectors is required to ensure older people are supported in the months following discharge from hospital to reduce avoidable rehospitalisations.

Establishing and evaluating a quality improvement collaborative to address hospital to home transitions for older people.

INTRODUCTION: Hospital use increases with age. Older people and their families have reported poor experiences of care at the time of discharge home from hospital. As part of a larger project, we established and evaluated a quality improvement collaborative to address hospital to home transitions for older people. METHODS: We convened an expert panel of 34 stakeholders to identify modifiable issues in the hospital-home transition period. We established a collaborative involving health professionals across a range of agencies working to common goals. Teams were supported by a network manager, three learning sessions and quality improvement methodology to address their identified area for improvement. We used mixed methods to evaluate whether the establishment of the quality improvement collaborative built networks, built capacity in the health professionals and improved the quality of care for older people. Evaluation methods included interviews, surveys, network mapping and case studies. RESULTS: Nine teams (n=41 participants) formed the collaborative and attended all meetings. Mapping showed an increase in networks between participants and organisations at the conclusion of the collaborative. Interview data showed that building relationships across services was one of the most important parts of the collaborative. Survey results revealed that most (77%) believed their quality improvement skills had developed through participation. Advice and regular meetings to progress project work were considered important in ensuring teams stayed focused. In terms of improving the quality of care, some participants indicated that they achieved the stated aims of their project better than expected (21%), most (41%) felt they achieved their aim as expected, 26% got close to their aim and the rest did not know the outcome (13%). CONCLUSIONS: Establishing a quality improvement collaborative was a positive activity in terms of building a network across organisations and progressing quality improvement projects which aimed to achieve the same overall goal.

Preventing chronic disease in overweight and obese patients with low health literacy using eHealth and teamwork in primary healthcare (HeLP-GP): a cluster randomised controlled trial.

OBJECTIVES: To evaluate a multifaceted intervention on diet, physical activity and health literacy of overweight and obese patients attending primary care. DESIGN: A pragmatic two-arm cluster randomised controlled trial. SETTING: Urban general practices in lower socioeconomic areas in Sydney and Adelaide. PARTICIPANTS: We aimed to recruit 800 patients in each arm. Baseline assessment was completed by 215 patients (120 intervention and 95 control). INTERVENTION: A practice nurse-led preventive health check, a mobile application and telephone coaching. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes were measured at baseline, 6 and 12 months, and included patient health and eHealth literacy, weight, waist circumference and blood pressure. Secondary outcomes included changes in diet and physical activity, preventive advice and referral, blood lipids, quality of life and costs. Univariate and multivariate analyses of difference-in-differences (DiD) estimates for each outcome were conducted. RESULTS: At 6 months, the intervention group, compared with the control group, demonstrated a greater increase in Health Literacy Questionnaire domain 8 score (ability to find good health information; mean DiD 0.22; 95% CI 0.01 to 0.44). There were similar differences for domain 9 score (understanding health information well enough to know what to do) among patients below the median at baseline. Differences were reduced and non-statistically significant at 12 months. There was a small improvement in diet scores at 6 months (DiD 0.78 (0.10 to 1.47); p=0.026) but not at 12 months. There were no differences in eHealth literacy, physical activity scores, body mass index, weight, waist circumference or blood pressure. CONCLUSIONS: Targeted recruitment and engagement were challenging in this population. While the intervention was associated with some improvements in health literacy and diet, substantial differences in other outcomes were not observed. More intensive interventions and using codesign strategies to engage the practices earlier may produce a different result. Codesign may also be valuable when targeting lower socioeconomic populations. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry (ACTRN 12617001508369) (http://www.ANZCTR.org.au/ACTRN12617001508369.aspx). TRIAL PROTOCOL: The protocol for this trial has been published (open access; https://bmjopen.bmj.com/content/8/6/e023239).

An integrated knowledge translation approach to address avoidable rehospitalisations and unplanned admissions for older people in South Australia: implementation and evaluation program plan.

BACKGROUND: Repeated admission to hospital can be stressful for older people and their families and puts additional pressure on the health care system. While there is some evidence about strategies to better integrate care, improve older patients' experiences at transitions of care, and reduce preventable hospital readmissions, implementing these strategies at scale is challenging. This program of research comprises multiple, complementary research activities with an overall goal of improving the care for older people after discharge from hospital. The program leverages existing large datasets and an established collaborative network of clinicians, consumers, academics, and aged care providers. METHODS: The program of research will take place in South Australia focusing on people aged 65 and over. Three inter-linked research activities will be the following: (1) analyse existing registry data to profile individuals at high risk of emergency department encounters and hospital admissions; (2) evaluate the cost-effectiveness of existing 'out-of-hospital' programs provided within the state; and (3) implement a state-wide quality improvement collaborative to tackle key interventions likely to improve older people's care at points of transitions. The research is underpinned by an integrated approach to knowledge translation, actively engaging a broad range of stakeholders to optimise the relevance and sustainability of the changes that are introduced. DISCUSSION: This project highlights the uniqueness and potential value of bringing together key stakeholders and using a multi-faceted approach (risk profiling; evaluation framework; implementation and evaluation) for improving health services. The program aims to develop a practical and scalable solution to a challenging health service problem for frail older people and service providers.