Using photovoice to explore Bolivian children's experiences of COVID-19.

Our capacity to facilitate the empowerment of children is dependent on our ability to understand their values and experiences. This study aimed to explore Bolivian children's experiences of COVID-19. This study used a participatory action research method, photovoice, which involved focus groups, individual interviews and the use of cameras by participants to capture their reality and express their ideas through photographs. Ten participants aged 12-15 years were recruited from a school in the municipality of Mecapaca in Bolivia. Thematic analysis was used to identify and report response patterns. Four themes were developed through analysis: (i) sadness and fear of getting sick, (ii) the challenges of online learning, (iii) the tension between traditional knowledge and modern medicine, and (iv) the role of nature and culture in supporting well-being-natural and cultural capital. The narratives and choice of images by the children illustrate some issues and experiences. These findings also highlighted the importance of considering and exploring how children's experiences and interactions with their habitat, nature and their physical environment impacts on their health and well-being.

Parents' ability to access community health occupational therapy services in a disadvantaged area: A proof of concept study.

INTRODUCTION: In New South Wales, children from disadvantaged backgrounds have poorer health outcomes and reduced access to health services than their more advantaged counterparts. This study aimed to identify barriers and enablers to accessing child and family occupational therapy services in a disadvantaged area. METHODS: This was a mixed methods study that included: (a) a retrospective analysis of de-identified routinely collected Community Health service utilisation data from 2016 to 2017, and a (b) face to face interview guided survey with parents and carers. RESULTS: The retrospective data analysis showed outreach at the targeted suburbs' Early Childhood Health Centres (ECHC) improved attendance for families living in these suburbs. Parents' responses indicated that they were able to access the Community Health Centre (CHC) and certain barriers to accessing the service remain, including difficulty in parking and not having a license or car to attend appointments. Low health literacy was also a barrier to accessing health appointments as parents were unaware of the range of services provided at CHC, did not know how to make appointments, or that these services did not generate out-of-pocket expenses to clients. Conversely, enablers that would make it easier for parents to attend appointments include the provision of home visits, after hours and weekend appointments, and outreach such as delivering services in community spaces such as the ECHCs, library, or mosque. CONCLUSION: This research suggests that outreach occupational therapy services are valued by families in this disadvantaged area and contribute towards improving access to allied health services for disadvantaged families with young children. However, additional work is required to increase awareness among disadvantaged families on the role of allied health in improving child development outcomes and to reduce some of the transport and logistical issues that can reduce access to health care.

An education intervention to improve decision making and health literacy among older Australians: a randomised controlled trial.

BACKGROUND: National policies seek to involve older Australian's in decisions regarding their care; however, research has found varying levels of decision self-efficacy and health literacy skills. An increasing number of older Australians use complementary medicine (CM). We examined the effectiveness of a CM educational intervention delivered using a web or DVD plus booklet format to increase older adults' decision self-efficacy and health literacy. METHODS: A randomised controlled trial was conducted. We recruited individuals aged over 65 years living in retirement villages or participating in community groups, in Sydney Australia. Participants were randomly allocated to receive a CM education intervention delivered using a website or DVD plus booklet versus booklet only. The primary outcome was decision self-efficacy. A secondary outcome included the Preparation for Decision-Making scale and health literacy. Outcomes were collected at 3 weeks, and 2 months from baseline, and analysed using an adjusted ANOVA, or repeated measures ANOVA. RESULT: We randomised 153 participants. Follow up at 3 weeks and 2 months was completed by 131 participants. There was a 14% (n = 22) attrition rate. At the end of the intervention, we found no significant differences between groups for decision self-efficacy (mean difference (MD) 3.8, 95% confidence interval (CI) -2.0 to 9.6 p = 0.20), there were no differences between groups on nine health literacy domains, and the Preparation for Decision-Making scale. Over 80% of participants in both groups rated the content as excellent or good. CONCLUSION: Decision self-efficacy improved for participants, but did not differ between groups. Decision self-efficacy and health literacy outcomes were not influenced by the delivery of education using a website, DVD or booklet. Participants found the resources useful, and rated the content as good or excellent. CM Web or DVD and booklet resources have the potential for wider application. TRIAL REGISTRATION: The trial was registered with the Australian New Zealand Clinical Trials Registry: ACTRN ( ACTRN12616000135415 ). The trial was registered on 5 February 2016.

The impact of mandatory iodine fortification and supplementation on pregnant and lactating women in Australia.

BACKGROUND AND OBJECTIVES: In Australia, two public health measures were introduced between 2009 and 2010 to reduce iodine deficiency. However there has been a shortage of information regarding their effectiveness and the ongoing prevalence of iodine deficiency in Australia. The primary aim of this study was to assess the extent to which these public health measures have reduced rates of iodine deficiency among pregnant and lactating women. METHODS AND STUDY DESIGN: A review was conducted to identify all studies published since January 2010 that quantitatively measured the iodine status of pregnant and/or lactating women in Australia. RESULTS: We found 25 publications, of which seven were included in this review after our exclusion criteria were applied. Of the seven included publications, three demonstrated the pregnant and lactating women in their studies to be iodine replete (median urinary iodine concentrations (MUIC) greater than 150 µg/L, or a breast milk iodine concentration (BMIC) of greater than 100 µg/L). The remaining four publications found MUIC of pregnant and lactating women to be below the 150 µg/L threshold, in the mild-to-moderate iodine deficiency category. Only two studies, documented iodine sufficiency among pregnant and lactating women in the absence of iodine supplementation. CONCLUSIONS: Many pregnant and lactating women in Australia remain at least mildly iodine deficient. Antenatal iodine supplementation was the factor most consistently associated with an adequate iodine status. Larger, more representative studies or sentinel studies with a National coordination are needed to understand the differences in iodine status that exist across the country.

Physicians' perspectives on clinical pharmacy services in Northern Sweden: a qualitative study.

BACKGROUND: In many countries, clinical pharmacists are part of health care teams that work to optimize drug therapy and ensure patient safety. However, in Sweden, clinical pharmacy services (CPSs) in hospital settings have not been widely implemented and regional differences exist in the uptake of these services. Physicians' attitudes toward CPSs and collaborating with clinical pharmacists may facilitate or hinder the implementation and expansion of the CPSs and the role of the clinical pharmacist in hospital wards. The aim of this study was to explore physicians' perceptions regarding CPSs performed at hospital wards in Northern Sweden. METHODS: Face-to-face semi-structured interviews were conducted with a purposive sample of nine physicians who had previously worked with clinical pharmacists between November 2014 and January 2015. Interviews were digitally recorded, transcribed and analysed using a constant comparison method. RESULTS: Different themes emerged regarding physicians' views of clinical pharmacy; two main interlinked themes were service factors and pharmacist factors. The service was valued and described in a positive way by all physicians. It was seen as an opportunity for them to learn more about pharmacological treatment and also an opportunity to discuss patient medication treatment in detail. Physicians considered that CPSs could improve patient outcomes and they valued continuity and the ability to build a trusting relationship with the pharmacists over time. However, there was a lack of awareness of the CPSs. All physicians knew that one of the pharmacist's roles is to conduct medication reviews, but most of them were only able to describe a few elements of what this service encompasses. Pharmacists were described as "drug experts" and their recommendations were perceived as clinically relevant. Physicians wanted CPSs to continue and to be implemented in other wards. CONCLUSIONS: All physicians were positive regarding CPSs and were satisfied with the collaboration with the clinical pharmacists. These findings are important for further implementation and expansion of CPSs, particularly in Northern Sweden.

Perceptions of shared care among survivors of colorectal cancer from non-English-speaking and English-speaking backgrounds: a qualitative study.

BACKGROUND: Colorectal cancer (CRC) survivors experience difficulty navigating complex care pathways. Sharing care between GPs and specialist services has been proposed to improve health outcomes in cancer survivors following hospital discharge. Culturally and Linguistically Diverse (CALD) groups are known to have poorer outcomes following cancer treatment but little is known about their perceptions of shared care following surgery for CRC. This study aimed to explore how non-English-speaking and English-speaking patients perceive care to be coordinated amongst various health practitioners. METHODS: This was a qualitative study using data from face to face semi-structured interviews and one focus group in a culturally diverse area of Sydney with non-English-speaking and English-speaking CRC survivors. Participants were recruited in community settings and were interviewed in English, Spanish or Vietnamese. Interviews were recorded, transcribed, and analysed by researchers fluent in those languages. Data were coded and analysed thematically. RESULTS: Twenty-two CRC survivors participated in the study. Participants from non-English-speaking and English-speaking groups described similar barriers to care, but non-English-speaking participants described additional communication difficulties and perceived discrimination. Non-English-speaking participants relied on family members and bilingual GPs for assistance with communication and care coordination. Factors that influenced the care pathways used by participants and how care was shared between the specialist and GP included patient and practitioner preference, accessibility, complexity of care needs, and requirements for assistance with understanding information and navigating the health system, that were particularly difficult for non-English-speaking CRC survivors. CONCLUSIONS: Both non-English-speaking and English-speaking CRC survivors described a blend of specialist-led or GP-led care depending on the complexity of care required, informational needs, and how engaged and accessible they perceived the specialist or GP to be. Findings from this study highlight the role of the bilingual GP in assisting CALD participants to understand information and to navigate their care pathways following CRC surgery.

A narrative review of the literature about people with intellectual disability who identify as lesbian, gay, bisexual, transgender, intersex or questioning.

This narrative review of the research literature presents a summary about the key issues facing people with intellectual disability (ID) who identify as lesbian, gay, bisexual, transgender, intersex or questioning (LGBTIQ). The aim of this review was to consolidate research of the topic; to identify whether any pilot studies reporting social/sexual/educational interventions had been published; and to offer some perspective on the type of future research required to better inform policy, practice and theory that may lead to better outcomes for people with ID who identify as LGBTIQ. Almost all of the research literature on the topic is either exploratory or descriptive which serves to outline the range of issues faced by people with ID who identify as LGBTIQ. Urgently needed as the next step, however, is a concerted effort to conduct a range of innovative educational and social interventions with collection of targeted and appropriate outcomes data.

Policymakers' experience of a capacity-building intervention designed to increase their use of research: a realist process evaluation.

BACKGROUND: An intervention's success depends on how participants interact with it in local settings. Process evaluation examines these interactions, indicating why an intervention was or was not effective, and how it (and similar interventions) can be improved for better contextual fit. This is particularly important for innovative trials like Supporting Policy In health with Research: an Intervention Trial (SPIRIT), where causal mechanisms are poorly understood. SPIRIT was testing a multi-component intervention designed to increase the capacity of health policymakers to use research. METHODS: Our mixed-methods process evaluation sought to explain variation in observed process effects across the six agencies that participated in SPIRIT. Data collection included observations of intervention workshops (n = 59), purposively sampled interviews (n = 76) and participant feedback forms (n = 553). Using a realist approach, data was coded for context-mechanism-process effect configurations (retroductive analysis) by two authors. RESULTS: Intervention workshops were very well received. There was greater variation of views regarding other aspects of SPIRIT such as data collection, communication and the intervention's overall value. We identified nine inter-related mechanisms that were crucial for engaging participants in these policy settings: (1) Accepting the premise (agreeing with the study's assumptions); (2) Self-determination (participative choice); (3) The Value Proposition (seeing potential gain); (4) 'Getting good stuff' (identifying useful ideas, resources or connections); (5) Self-efficacy (believing 'we can do this!'); (6) Respect (feeling that SPIRIT understands and values one's work); (7) Confidence (believing in the study's integrity and validity); (8) Persuasive leadership (authentic and compelling advocacy from leaders); and (9) Strategic insider facilitation (local translation and mediation). These findings were used to develop tentative explanatory propositions and to revise the programme theory. CONCLUSION: This paper describes how SPIRIT functioned in six policy agencies, including why strategies that worked well in one site were less effective in others. Findings indicate a complex interaction between participants' perception of the intervention, shifting contextual factors, and the form that the intervention took in each site. Our propositions provide transferable lessons about contextualised areas of strength and weakness that may be useful in the development and implementation of similar studies.

Should I stay or should I go? Exploring the job preferences of allied health professionals working with people with disability in rural Australia.

INTRODUCTION: The uneven distribution of allied health professionals (AHPs) in rural and remote Australia and other countries is well documented. In Australia, like elsewhere, service delivery to rural and remote communities is complicated because relatively small numbers of clients are dispersed over large geographic areas. This uneven distribution of AHPs impacts significantly on the provision of services particularly in areas of special need such as mental health, aged care and disability services. OBJECTIVE: This study aimed to determine the relative importance that AHPs (physiotherapists, occupational therapists, speech pathologists and psychologists - "therapists") living in a rural area of Australia and working with people with disability, place on different job characteristics and how these may affect their retention. METHODS: A cross-sectional survey was conducted using an online questionnaire distributed to AHPs working with people with disability in a rural area of Australia over a 3-month period. Information was sought about various aspects of the AHPs' current job, and their workforce preferences were explored using a best-worst scaling discrete choice experiment (BWSDCE). Conditional logistic and latent class regression models were used to determine AHPs' relative preferences for six different job attributes. RESULTS: One hundred ninety-nine AHPs completed the survey; response rate was 51 %. Of those, 165 completed the BWSDCE task. For this group of AHPs, "high autonomy of practice" is the most valued attribute level, followed by "travel BWSDCE arrangements: one or less nights away per month", "travel arrangements: two or three nights away per month" and "adequate access to professional development". On the other hand, the least valued attribute levels were "travel arrangements: four or more nights per month", "limited autonomy of practice" and "minimal access to professional development". Except for "some job flexibility", all other attributes had a statistical influence on AHPs' job preference. Preferences differed according to age, marital status and having dependent children. CONCLUSIONS: This study allowed the identification of factors that contribute to AHPs' employment decisions about staying and working in a rural area. This information can improve job designs in rural areas to increase retention.

Factors affecting retention of allied health professionals working with people with disability in rural New South Wales, Australia: discrete choice experiment questionnaire development.

OBJECTIVE: This paper describes the development of a discrete choice experiment (DCE) questionnaire to identify the factors (attributes) that allied health professionals (AHPs) working with people with disability identify as important to encouraging them to remain practising in rural areas. METHODS: Focus groups and semi-structured interviews were conducted with 97 purposively selected service providers working with people with disability in rural New South Wales, Australia. Focus groups and interviews were digitally recorded, transcribed, and analysed using a modified grounded theory approach involving thematic analysis and constant comparison. RESULTS: Six attributes that may influence AHPs working with people with disability in rural areas to continue to do so were inductively identified: travel arrangements, work flexibility, professional support, professional development, remuneration, and autonomy of practice. The qualitative research information was combined with a policy review to define these retention factors and ensure that they are amenable to policy changes. CONCLUSION: The use of various qualitative research methods allowed the development of a policy-relevant DCE questionnaire that was grounded in the experience of the target population (AHPs).

'It was serendipity': a qualitative study of academic careers in medical education.

CONTEXT: Despite a demand for educational expertise in medical universities, little is known of the roles of medical educators and the sustainability of academic careers in medical education. We examined the experiences and career paths of medical educators from diverse professional backgrounds seeking to establish, maintain and strengthen their careers in medical schools. METHODS: Semi-structured interviews were conducted with 44 lead and early-career medical educators from all 21 Australian and New Zealand medical schools. Questions explored career beginnings, rewards and challenges. Transcripts underwent systematic coding and independent thematic analysis. Final themes were confirmed by iterative review and member checking. Analysis was informed by Bourdieu's concepts of field (a social space for hierarchical interactions), habitus (individual dispositions which influence social interactions) and capital (economic, symbolic, social and cultural forms of power). RESULTS: Participants provided diverse accounts of what constitutes the practice of medical education. Serendipitous career entry and little commonality of professional backgrounds and responsibilities suggest an ambiguous habitus with ill-defined career pathways. Within the field of medicine as enacted in medical schools, educators have invisible yet essential roles, experiencing tension between service expectations, a lesser form of capital, and demands for more highly valued forms of scholarship. Participants reported increasing expectations to produce research and obtain postgraduate qualifications to enter and maintain their careers. Unable to draw upon cultural capital accrued from clinical work, non-clinician educators faced additional challenges. To strengthen their position, educators consciously built social capital through essential service relationships, capitalising on times when education takes precedence, such as curriculum renewal and accreditation. CONCLUSIONS: Bourdieu's theory provides insight into medical educator career paths and the positioning of medical education within medical schools. Medical educators have an indistinct practice, and limited cultural capital in the form of research outputs. In order to maintain and strengthen their careers, educators must create alternative sources of capital, through fostering collaborative alliances.

Who are they and what do they do? Profile of allied health professionals working with people with disabilities in rural and remote New South Wales.

OBJECTIVE: To explore the characteristics of allied health professionals (AHPs) working with people with disabilities in western New South Wales (NSW). DESIGN: A cross-sectional survey was conducted using an online questionnaire. SETTING: Rural western NSW. PARTICIPANTS: AHPs including physiotherapists, speech pathologists, occupational therapists and psychologists ('therapists') working with people with disabilities. MAIN OUTCOME MEASURE: AHPs characteristics. RESULTS: The majority of respondents were women (94%), with a mean age of 39 years; average time since qualification was 14 years; mean years in current position was 6. Most worked with people with a lifelong disability. Two thirds reported that family ties kept them in rural areas; 71% grew up in a rural/remote area. Most participants (94%) enjoyed the rural lifestyle, and 84% reported opportunities for social interaction as good or very good. Participants with dependent children were less likely to cease working in western NSW within 5 years than those without dependent children (P < 0.05). CONCLUSIONS: The characteristics of therapists working with people with disabilities in rural NSW were identified. Overall working, but also social conditions and community attachment were important for this group. Understanding the workforce will contribute to policy development to meet increasing demands for therapy services.

Health inequalities and development plans in Iran; an analysis of the past three decades (1984-2010).

INTRODUCTION: Reducing inequalities in health care is one of the main challenges in all countries. In Iran as in other oil-exporting upper middle income countries, we expected to witness fewer inequalities especially in the health sector with the increase in governmental revenues. METHODS: This study presents an inequalities assessment of health care expenditures in Iran. We used data from the Household Income and Expenditure Survey (HIES) in Iran from 1984-2010. The analysis included 308,735 urban and 342,532 rural households. RESULTS: The results suggest heightened inequality in health care expenditures in Iran over the past three decades, including an increase in the gap between urban and rural areas. Furthermore, inflation has affected the poor more than the rich. The Kakwani progressivity index in all years is positive, averaging 0.436 in rural and 0.470 in urban areas during the time period of analysis. Compared to inequality in income distribution over the last 30 years, health expenditures continuously show more inequality and progressivity over the same period of time. CONCLUSIONS: According to the result of our study, during this period Iran introduced four National Development Plans (NDPs); however, the NDPs failed to provide sustainable strategies for reducing inequalities in health care expenditures. Policies that protect vulnerable groups should be prioritized.

Identifying priorities for Australian disability research using Q methodology.

BACKGROUND: Globally, there are over an estimated one billion people with disability. Research priorities with a focus on diagnosis and treatment of conditions or policy and service initiatives, traditionally decided by researchers, may not align with priorities of those with lived experience of disability. OBJECTIVE: To explore and inform disability research for Australia, including perspectives of people with disability. METHODS: As part of a research program, we used Q methodology to explore "what should guide the Australian research agenda?" People with disability, their families, community organizations and researchers were purposively recruited and sorted 25 statements, developed iteratively using data collated from systematic research mapping and a prior consultation process. The sorting grid ranged from -4 to +4, according to "Which topics should guide disability research the least to the most?" Factor analysis revealed four distinct but interrelated participant viewpoints. RESULTS: 52 participants (65 % female, aged 18-65+ years, 37 % people living with disability), sorted the statements. Viewpoint 1 - design and delivery of services across the lifespan. Viewpoint 2 - understanding the diverse experience of those with disability. Viewpoint 3 - designing systems to address impacts of disability for the individual, their families and society. Viewpoint 4 - addressing mental health for those with disability no matter where they live. CONCLUSION: These viewpoints focused on design and delivery of services to address the impacts of disabling environments and attitudes on individuals living with impairments, their families and society. The four viewpoints provide a framework for future disability research in consultation with those with lived experience.

Community attitudes to remunerated blood donation in Australia: results from a national telephone survey.

BACKGROUND: Blood in Australia is sourced through voluntary, non-remunerated donations. With periodic shortages in supply, increasing demand for blood products and a donor base that is perceived to be unsustainable, remuneration has been proposed as a means to improve donation rates. OBJECTIVE: To examine community attitudes to remunerated blood donation in Australia. METHOD: A national random telephone survey of Australian adults age 18-70 was conducted (n = 1024). Associations were tested using a chi-square (χ(2)) test for linear distribution. RESULTS: Reimbursement for the cost of travel to donate blood was supported by more respondents (46%) than reimbursement for time (19%). Non-donors were more likely to support a payment compared to donors (P = 0.002). Twelve per cent of respondents thought they would be more likely to donate if remunerated while 10% thought they would be less likely. The majority (76%) thought that a payment would not change whether or not they would donate, while 85% thought that it would make other people more likely to donate. The average amount considered to be reasonable reimbursement was AU$30. CONCLUSION: Despite the common perception that other people would be motivated to donate blood with the introduction of a financial incentive, remuneration may provide minimal incentive in Australia and is unlikely to increase donor participation for the time being.

Surgeons' views of health technology assessment in Australia: online pilot survey.

INTRODUCTION: Many governments have introduced health technology assessment (HTA) as an important tool to manage the uptake and use of health-related technologies efficiently. Although surgeons play a central role in the uptake and diffusion of new technologies, little is known about their opinion and understanding of the HTA role and process. METHODS: A cross-sectional pilot study was conducted using an online questionnaire which was distributed to Fellows of the Royal Australasian College of Surgeons over a 4-week period. Information was sought about knowledge and views of the HTA process. Descriptive statistics were used to summarize the data, frequencies, and proportions were calculated. RESULTS: Sixty-two surgeons completed the survey; of these, 55 percent reported their primary work place as a public hospital. Twenty-four percent of the participants reported that they had never heard of the HTA agency and 60 percent reported that surgical procedures are most likely to be introduced in the Australian healthcare system at the public hospital level (which is beyond the HTA's scope and dealt with at a state level). However, 61 percent considered that decisions about funding and adoption of new technologies should take place at the national level. CONCLUSIONS: This survey provides some evidence that many surgeons remain unaware of the federal government's HTA process but still value evidence-based information. In order for HTA to be an effective aid to rational adoption of health-related technologies, there is a need for an evidence-based approach that is integrated and is accepted and understood by the medical professions.

Integrating evidence into policy and sustainable disability services delivery in western New South Wales, Australia: the 'wobbly hub and double spokes' project.

BACKGROUND: Policy that supports rural allied health service delivery is important given the shortage of services outside of Australian metropolitan centres. The shortage of allied health professionals means that rural clinicians work long hours and have little peer or service support. Service delivery to rural and remote communities is further complicated because relatively small numbers of clients are dispersed over large geographic areas. The aim of this five-year multi-stage project is to generate evidence to confirm and develop evidence-based policies and to evaluate their implementation in procedures that allow a regional allied health workforce to more expeditiously respond to disability service need in regional New South Wales, Australia. METHODS/DESIGN: The project consists of four inter-related stages that together constitute a full policy cycle. It uses mixed quantitative and qualitative methods, guided by key policy concerns such as: access, complexity, cost, distribution of benefits, timeliness, effectiveness, equity, policy consistency, and community and political acceptability. Stage 1 adopts a policy analysis approach in which existing relevant policies and related documentation will be collected and reviewed. Policy-makers and senior managers within the region and in central offices will be interviewed about issues that influence policy development and implementation. Stage 2 uses a mixed methods approach to collecting information from allied health professionals, clients, and carers. Focus groups and interviews will explore issues related to providing and receiving allied health services. Discrete Choice Experiments will elicit staff and client/carer preferences. Stage 3 synthesises Stage 1 and 2 findings with reference to the key policy issues to develop and implement policies and procedures to establish several innovative regional workforce and service provision projects. Stage 4 uses mixed methods to monitor and evaluate the implementation and impact of new or adapted policies that arise from the preceding stages. DISCUSSION: The project will provide policy makers with research evidence to support consideration of the complex balance between: (i) the equitable allocation of scarce resources; (ii) the intent of current eligibility and prioritisation policies; (iii) workforce constraints (and strengths); and (iv) the most effective, evidence-based clinical practice.

Prioritizing strategies for comprehensive liver cancer control in Asia: a conjoint analysis.

BACKGROUND: Liver cancer is a complex and burdensome disease, with Asia accounting for 75% of known cases. Comprehensive cancer control requires the use of multiple strategies, but various stakeholders may have different views as to which strategies should have the highest priority. This study identified priorities across multiple strategies for comprehensive liver cancer control (CLCC) from the perspective of liver cancer clinical, policy, and advocacy stakeholders in China, Japan, South Korea and Taiwan. Concordance of priorities was assessed across the region and across respondent roles. METHODS: Priorities for CLCC were examined as part of a cross-sectional survey of liver cancer experts. Respondents completed several conjoint-analysis choice tasks to prioritize 11 strategies. In each task, respondents judged which of two competing CLCC plans, consisting of mutually exclusive and exhaustive subsets of the strategies, would have the greatest impact. The dependent variable was the chosen plan, which was then regressed on the strategies of different plans. The restricted least squares (RLS) method was utilized to compare aggregate and stratified models, and t-tests and Wald tests were used to test for significance and concordance, respectively. RESULTS: Eighty respondents (69.6%) were eligible and completed the survey. Their primary interests were hepatitis (26%), hepatocellular carcinoma (HCC) (58%), metastatic liver cancer (10%) and transplantation (6%). The most preferred strategies were monitoring at-risk populations (p<0.001), clinician education (p<0.001), and national guidelines (p<0.001). Most priorities were concordant across sites except for three strategies: transplantation infrastructure (p=0.009) was valued lower in China, measuring social burden (p=0.037) was valued higher in Taiwan, and national guidelines (p=0.025) was valued higher in China. Priorities did not differ across stakeholder groups (p=0.438). CONCLUSIONS: Priorities for CLCC in Asia include monitoring at-risk populations, clinician education, national guidelines, multidisciplinary management, public awareness and centers of excellence. As most priorities are relatively concordant across the region, multilateral approaches to addressing comprehensive liver cancer would be beneficial. However, where priorities are discordant among sites, such as transplantation infrastructure, strategies should be tailored to local needs.

Using best-worst scaling in horizon scanning for hepatocellular carcinoma technologies.

OBJECTIVES: There is a growing need for efficient procedures for identification of emerging technologies by horizon scanning systems. We demonstrate the value of best-worst scaling (BWS) in exploring clinicians' views on emerging technologies that will impact outcomes in hepatocellular carcinoma (HCC) in the next 5 to 10 years. METHODS: Clinicians in Asia, Europe, and the United States were surveyed and their views about eleven emerging technologies relevant to HCC were explored using BWS (case 1). This involved systematically presenting respondents with subsets of five technologies and asking them to identify those that will have the most and least impact on HCC within 5 to 10 years. Statistical analysis was based on sequential best-worst and analyzed using conditional logistic regression. RESULTS: A total of 120 clinicians uniformly distributed across ten countries completed the survey (37 percent response rate). Respondents were predominately hepatologist (41 percent) who focused on HCC (65 percent) and had national influence in this field (39 percent). Respondents viewed molecular targeted therapy (p < .001) and early detection of HCC (p < .001) as having most potential, while improved surgical techniques (p < .001) and biopsy free HCC diagnostics (p < .001) were viewed upon negatively. CONCLUSIONS: We demonstrate that BWS could be an important research tool to facilitate horizon scanning and HTA more broadly. Our research demonstrates the value of including clinicians' preferences as a source of data in horizon scanning, but such methods could be used to incorporate the opinions of a broad array of stakeholders, including those in advocacy and public policy.

Breaking up is hard to do: why disinvestment in medical technology is harder than investment.

Healthcare technology is a two-edged sword - it offers new and better treatment to a wider range of people and, at the same time, is a major driver of increasing costs in health systems. Many countries have developed sophisticated systems of health technology assessment (HTA) to inform decisions about new investments in new healthcare interventions. In this paper, we question whether HTA is also the appropriate framework for guiding or informing disinvestment decisions. In exploring the issues related to disinvestment, we first discuss the various HTA frameworks which have been suggested as a means of encouraging or facilitating disinvestment. We then describe available means of identifying candidates for disinvestment (comparative effectiveness research, clinical practice variations, clinical practice guidelines) and for implementing the disinvestment process (program budgeting and marginal analysis (PBMA) and related techniques). In considering the possible reasons for the lack of progress in active disinvestment, we suggest that HTA is not the right framework as disinvestment involves a different decision making context. The key to disinvestment is not just what to stop doing but how to make it happen - that is, decision makers need to be aware of funding disincentives.