Piloting a shared decision-making clinician training intervention in maternity care in Australia: A mixed methods study.

PROBLEM: Implementation of woman-centred care in evidence-based maternity practice requires clinicians to be skilled in shared decision-making, yet there is limited training or research into such interventions. BACKGROUND: Shared decision-making enables women to make informed decisions in partnership with clinicians where there are varied clinical options in relation to indications for and timing of planned birth. AIM: We aimed to develop a shared decision-making training intervention and evaluate its feasibility and acceptability to midwives and obstetricians. METHODS: The intervention was co-designed by midwifery and medical clinician-researchers, and a consumer representative. Online training and demonstration videos were distributed to midwives and obstetricians in three Sydney hospitals, followed by two online workshops in 2021 and 2022 where participants practised shared decision-making in roleplaying scenarios tailored to timing of birth. Training was evaluated using post-workshop and post-training surveys and semi-structured qualitative interviews. FINDINGS: The training workshop format, duration and content were well received. Barriers to the uptake of shared decision-making were time, paternalistic practices and fear of repercussions of centring women in the decision-making process. DISCUSSION: The intervention enabled midwifery and medical colleagues to learn communication repertoires from each other in woman-centred discussions around timing of birth. Roleplay scenarios enabled participants to observe and provide feedback on their colleagues' shared decision-making practices, while providing a space for collective reflection on ways to promote, and mitigate barriers to, its implementation in practice. CONCLUSION: Shared decision-making training supports maternity clinicians in developing skills that implement woman-centred care in the timing of planned birth.

Staff- and service-level factors associated with organisational readiness to implement a clinical pathway for the identification, assessment, and management of anxiety and depression in adults with cancer.

BACKGROUND: Organisational readiness is recognised as a key factor impacting the successful translation of research findings into practice. Within psycho-oncology, measuring organisational readiness and understanding factors impacting organisational readiness is crucial as it is often challenging to implement evidence-based findings into routine cancer care. In this quantitative study, we examined the level of organisational readiness of cancer services preparing to implement a clinical pathway for the screening, assessment, and management of anxiety and depression in adult cancer patients (the ADAPT CP) within a cluster randomised controlled trial and sought to identify staff- and service-level factors associated with organisational readiness. METHODS: Multidisciplinary staff across 12 Australian cancer services were identified. Their perceptions of their services' readiness to implement the ADAPT CP in the cancer stream or treatment modality selected within their service was assessed prior to implementation using the Organizational Readiness for Implementing Change scale. Data collection included staff demographic and professional characteristics, and their perception of the ADAPT CP using a set of 13 study-specific survey items. Service characteristics were captured using a site profile audit form and workflows during site engagement. RESULTS: Fourteen staff- and service-level factors were identified as potentially impacting organisational readiness. To identify factors that best explained organisational readiness, separate univariate analyses were conducted for each factor, followed by a backward elimination regression. Compared to services that implemented the ADAPT CP in one treatment modality, those opting for four treatment modalities had significantly higher organisational readiness scores. Staff in administrative/technical support/non-clinical roles had significantly higher organisational readiness scores compared to psychosocial staff. Higher organisational readiness scores were also significantly related to more positive perceptions of the ADAPT CP. CONCLUSIONS: Readiness to implement an anxiety and depression clinical pathway within 12 oncology services was high. This may be attributed to the extensive engagement with services prior to implementation. The factors associated with organisational readiness highlight the importance of ensuring adequate resourcing and supporting staff to implement change, effectively communicating the value of the change, and taking a whole-of-service approach to implementing the change. Future longitudinal studies may identify factors associated with ongoing readiness and engagement prior to implementation. TRIAL REGISTRATION: The ADAPT RCT was registered prospectively with the ANZCTR on 22/03/2017. Trial ID ACTRN12617000411347. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372486&isReview=true .

Interventions to support decision-making, health literacy and self-management in ethnic-minority adults living with chronic kidney disease: a systematic review.

Optimal patient care is directed by clinical practice guidelines, with emphasis on shared decision-making. However, guidelines-and interventions to support their implementation-often do not reflect the needs of ethnic minorities, who experience inequities in chronic kidney disease (CKD) prevalence and outcomes. This review aims to describe what interventions exist to promote decision-making, self-management and/or health literacy for ethnic-minority people living with CKD, describe intervention development and/or adaptation processes, and explore the impact on patient outcomes. Six databases were searched (MEDLINE, PsychINFO, Scopus, EMBASE, CINAHL, InformitOnline) and two reviewers independently extracted study data and assessed risk of bias. Twelve studies (n = 291 participants), conducted in six countries and targeting nine distinct ethnic-minority groups, were included. Intervention strategies consisted of: (i) face-to-face education/skills training (three studies, n = 160), (ii) patient education materials (two studies, n = unspecified), (iii) Cultural Health Liaison Officer (six studies, n = 106) or (iv) increasing access to healthcare (three studies, n = 25). There was limited description of cultural targeting/tailoring. Where written information was translated into languages other than English, the approach was exact translation without other cultural adaptation. Few studies reported on community-based research approaches, intervention adaptations requiring limited or no literacy (e.g. infographics; photographs and interviews with local community members) and the inclusion of Cultural Health Liaison Officer as part of intervention design. No community-based interventions were evaluated for their impact on clinical or psychosocial outcomes. All interventions conducted in the hospital settings reported favourable outcomes (e.g. reduction in blood pressure) compared with routine care but were limited by methodological issues.

Effect of core versus enhanced implementation strategies on adherence to a clinical pathway for managing anxiety and depression in cancer patients in routine care: a cluster randomised controlled trial.

BACKGROUND: Optimal strategies to facilitate implementation of evidence-based clinical pathways are unclear. We evaluated two implementation strategies (Core versus Enhanced) to facilitate implementation of a clinical pathway for the management of anxiety and depression in cancer patients (the ADAPT CP). METHODS: Twelve cancer services in NSW Australia were cluster randomised, stratified by service size, to the Core versus Enhanced implementation strategy. Each strategy was in place for 12 months, facilitating uptake of the ADAPT CP (the intervention being implemented). The Core strategy included a lead team with champions, staff training and awareness campaigns prior to implementation, plus access to feedback reports and telephone or online support during implementation. The Enhanced strategy included all Core supports plus monthly lead team meetings, and proactive, ongoing advice on managing barriers, staff training and awareness campaigns throughout implementation. All patients at participating sites were offered the ADAPT CP as part of routine care, and if agreeable, completed screening measures. They were allocated a severity step for anxiety/depression from one (minimal) to five (severe) and recommended management appropriate to their severity step. Multi-level mixed-effect regression analyses examined the effect of Core versus Enhanced implementation strategy on adherence to the ADAPT CP (binary primary outcome: adherent ≥ 70% of key ADAPT CP components achieved versus non-adherent < 70%), with continuous adherence as a secondary outcome. Interaction between study arm and anxiety/depression severity step was also explored. RESULTS: Of 1280 registered patients, 696 (54%) completed at least one screening. As patients were encouraged to re-screen, there were in total 1323 screening events (883 in Core and 440 in Enhanced services). The main effect of implementation strategy on adherence was non-significant in both binary and continuous analyses. Anxiety/depression step was significant, with adherence being higher for step 1 than for other steps (p = 0.001, OR = 0.05, 95% CI 0.02-0.10). The interaction between study arm and anxiety/depression step was significant (p = 0.02) in the continuous adherence analysis only: adherence was significantly higher (by 7.6% points (95% CI 0.08-15.1%) for step 3 in the Enhanced arm (p = .048) and trending to significance for step 4. DISCUSSION: These results support ongoing implementation effort for the first year of implementation to ensure successful uptake of new clinical pathways in over-burdened clinical services. TRIAL REGISTRATION: ANZCTR Registration: ACTRN12617000411347 (Trial registered 22/03/2017; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372486&isReview=true ).

Multiple Automated Health Literacy Assessments of Written Health Information: Development of the SHeLL (Sydney Health Literacy Lab) Health Literacy Editor v1.

Producing health information that people can easily understand is challenging and time-consuming. Existing guidance is often subjective and lacks specificity. With advances in software that reads and analyzes text, there is an opportunity to develop tools that provide objective, specific, and automated guidance on the complexity of health information. This paper outlines the development of the SHeLL (Sydney Health Literacy Lab) Health Literacy Editor, an automated tool to facilitate the implementation of health literacy guidelines for the production of easy-to-read written health information. Target users were any person or organization that develops consumer-facing education materials, with or without prior experience with health literacy concepts. Anticipated users included health professionals, staff, and government and nongovernment agencies. To develop this tool, existing health literacy and relevant writing guidelines were collated. Items amenable to programmable automated assessment were incorporated into the Editor. A set of natural language processing methods were also adapted for use in the SHeLL Editor, though the approach was primarily procedural (rule-based). As a result of this process, the Editor comprises 6 assessments: readability (school grade reading score calculated using the Simple Measure of Gobbledygook (SMOG)), complex language (percentage of the text that contains public health thesaurus entries, words that are uncommon in English, or acronyms), passive voice, text structure (eg, use of long paragraphs), lexical density and diversity, and person-centered language. These are presented as global scores, with additional, more specific feedback flagged in the text itself. Feedback is provided in real-time so that users can iteratively revise and improve the text. The design also includes a "text preparation" mode, which allows users to quickly make adjustments to ensure accurate calculation of readability. A hierarchy of assessments also helps users prioritize the most important feedback. Lastly, the Editor has a function that exports the analysis and revised text. The SHeLL Health Literacy Editor is a new tool that can help improve the quality and safety of written health information. It provides objective, immediate feedback on a range of factors, complementing readability with other less widely used but important objective assessments such as complex and person-centered language. It can be used as a scalable intervention to support the uptake of health literacy guidelines by health services and providers of health information. This early prototype can be further refined by expanding the thesaurus and leveraging new machine learning methods for assessing the complexity of the written text. User-testing with health professionals is needed before evaluating the Editor's ability to improve the health literacy of written health information and evaluating its implementation into existing Australian health services.

Midwives' perspectives of intravenous fluid management and fluid balance documentation in labour: A qualitative reflexive thematic analysis study.

AIM: To describe current practice, examine the influences and explore barriers and facilitators to accurate documentation, for the administration of intravenous fluids during labour. DESIGN: A descriptive qualitative study was performed. METHODS: Qualitative semi-structured interviews were conducted with Registered Midwives working across Australia. Midwives were recruited via email and social media advertisements. A maximum variation sampling strategy was used to identify potential participants. Interview questions explored four main areas: (i) understanding of indications for IV fluids in labour; (ii) identification of current practice; (iii) barriers to documentation and (iv) benefits and complications of IV fluid administration. Reflexive thematic analysis of recorded-transcribed interviews was conducted. RESULTS: Eleven midwives were interviewed. Clinical practice variation across Australia was recognized. Midwives reported a potential risk of harm for women and babies and a current lack of evidence, education and clinical guidance contributing to uncertainty around the use of IV fluids in labour. Overall, eight major themes were identified: (i) A variable clinical practice; (ii) Triggers and habits; (iii) Workplace and professional culture; (iv) Foundational knowledge; (v) Perception of risk; (vi) Professional standards and regulations; (vii) The importance of monitoring maternal fluid balance and (viii) barriers and facilitators to fluid balance documentation. CONCLUSION: There was widespread clinical variation identified and midwives reported a potential risk of harm. The major themes identified will inform future quantitative research examining the impact of IV fluids in labour. IMPACT: The implications of this research are important and potentially far-reaching. The administration of IV fluids to women in labour is a common clinical intervention. However, there is limited evidence available to guide practice. This study highlights the need for greater education and evidence examining maternal and neonatal outcomes to provide improved clinical guidance.

Implementing a web-based system of screening for symptoms and needs using patient-reported outcomes in people with cancer.

PURPOSE: To evaluate the implementation of a web-based system of screening for symptoms and needs in people with diverse cancers in a general hospital in Australia. METHODS: This was a prospective, single-arm, pragmatic intervention study. After local adaptation of an online portal and training, cancer nurses were asked to register patients to screen via the portal in clinic or at home. Symptoms were scored according to severity, and scores above cut-off were reported to nurses for assessment and management, according to best practice. RESULTS: Fifteen nurses working across diverse tumour types agreed to approach patients for screening. Of these, 7 nurses approached 68 patients, with 5 approaching more than 1 during the 7-month study period. Forty-seven (69%) patients completed screening, and 22 rescreened at least once. At first screening, 33 (70%) patients reported at least one symptom, most commonly tiredness (n = 27; 57%), reduced wellbeing (n = 24; 51%) and drowsiness (n = 17; 36%). Of the total 75 screens undertaken during the study, 56 (75%) identified at least one symptom, and 22 (29%) identified at least one severe symptom. All patients with a positive first screen were followed up by a nurse assessment and intervention-mostly reassurance (n = 19, 59%) or referral to another health professional (n = 11, 34%). CONCLUSION: Screening for symptoms and needs using a web-based portal identified many unmet needs, but the uptake of this intervention by nurses and patients was lower than expected.

Evaluation of the SUCCESS Health Literacy App for Australian Adults With Chronic Kidney Disease: Protocol for a Pragmatic Randomized Controlled Trial.

BACKGROUND: We developed a smartphone app-the SUCCESS (Supporting Culturally and Linguistically Diverse CKD Patients to Engage in Shared Decision-Making Successfully) app-to support Australian adults with kidney failure undertaking dialysis to actively participate in self-management and decision-making. The content of the SUCCESS app was informed by a theoretical model of health literacy that recognizes the importance of reducing the complexity of health information as well as providing skills necessary to access, understand, and act on this information. OBJECTIVE: The purpose of this study is to investigate the efficacy of the SUCCESS app intervention. METHODS: We designed a multicenter pragmatic randomized controlled trial to compare the SUCCESS app plus usual care (intervention) to usual care alone (control). A total of 384 participants receiving in-center or home-based hemodialysis or peritoneal dialysis will be recruited from six local health districts in the Greater Sydney region, New South Wales, Australia. To avoid intervention contamination, a pragmatic randomization approach will be used for participants undergoing in-center dialysis, in which randomization will be based on the days they receive hemodialysis and by center (ie, Monday, Wednesday, and Friday or Tuesday, Thursday, and Saturday). Participants undergoing home-based dialysis will be individually randomized centrally using simple randomization and two stratification factors: language spoken at home and research site. Consenting participants will be invited to use the SUCCESS app for 12 months. The primary endpoints, which will be assessed after 3, 6, and 12 months of app usage, are health literacy skills, evaluated using the Health Literacy Questionnaire; decision self-efficacy, evaluated using the Decision Self-Efficacy Scale; and rates of unscheduled health encounters. Secondary outcomes include patient-reported outcomes (ie, quality of life, evaluated with the 5-level EQ-5D; knowledge; confidence; health behavior; and self-management) and clinical outcomes (ie, symptom burden, evaluated with the Palliative care Outcome Scale-Renal; nutritional status, evaluated with the Patient-Generated Subjective Global Assessment; and intradialytic weight gain). App engagement will be determined via app analytics. All analyses will be undertaken using an intention-to-treat approach comparing the intervention and usual care arms. RESULTS: The study has been approved by Nepean Blue Mountains Human Research Ethics Committee (2020/ETH00910) and recruitment has begun at nine sites. We expect to finalize data collection by 2023 and publish the manuscript by 2024. CONCLUSIONS: Enhancing health literacy skills for patients undergoing hemodialysis is an important endeavor, given the association between poor health literacy and poor health outcomes, especially among culturally diverse groups. The findings from this trial will be published in peer-reviewed journals and disseminated at conferences, and updates will be shared with partners, including participating local health districts, Kidney Health Australia, and consumers. The SUCCESS app will continue to be available to all participants following trial completion. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry (ANZCTR) ACTRN12621000235808; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380754&isReview=true. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/39909.

Implementing shared decision-making in Australia.

Person-centred care (PCC) and shared decision-making (SDM) are part of national clinical standards for an increasing number of areas of health care delivery. In addition to existing standards for accrediting hospitals, day surgery facilities, public dental services and medical education in Australia, new standards governing primary health care and digital mental health services have been added. Implementation and measurement of PCC and SDM to comply with standards, and training of health professionals, remain challenges for the Australian health sector. Consumer involvement in health research, policy and clinical service governance continues to increase and the National Health and Medical Research Council has begun to encourage consumer and community involvement in health and medical research. This increased consumer engagement and moves towards more PCC provision is reflected in a focus on encouraging patients to ask questions during their clinical care and supports improvements in consumer health literacy. SDM support tools are now being culturally adapted whilst a need for more systemic approaches to their development and implementation persists. With increasing resources and tools for all aspects of PCC and SDM challenges to find sustainable solutions to ensure tools are kept up to date with the best available evidence remain.

A web-based comprehensive head and neck cancer patient education and support needs program: Usability testing.

Background: With increasing accessibility of the World Wide Web, patients are using it to obtain patient education materials (PEM). With this in mind, our group (surgeons, radiation oncologists, medical oncologists, nursing, allied health professionals and academic researchers) developed a comprehensive information resource for patients with head and neck cancer (HNC), the Head and Neck Cancer Australia, formerly Beyond Five website. The aim of this study was to determine patient usability of the Head and Neck Cancer Australia website. Methods: Usability testing (Cognitive walkthrough & Think-Aloud) in 18 patients treated for HNC was undertaken at a Cancer centre (anonymous for reviewers). Results: The tasks rated easiest by patients were finding information on psychological well-being (mean time spent: 66 s, range: 10-565), health and well-being effecting quality of life (mean time spent: 36 s, range 9-117) and carer information (mean time spent: 10 s, range 3-35). Patients indicated the website contained a lot of information, covers most topics, was a trusted source of information and a springboard to other information. Conclusions: The Head and Neck Cancer Australia website provides a wide range of information and support in multiple formats available to HNC patients. Further refinements in design, navigation and website instructions are needed to allow effective patient interaction.

Promise unfulfilled: Implementing web-based psychological therapy in routine cancer care, a qualitative study of oncology health professionals' attitudes.

BACKGROUND: Web-based mental health interventions (e-MhIs) show promise for increasing accessibility and acceptability of therapy for cancer patients. AIM: This study aimed to elicit health professionals' (HPs) views on optimal models for including e-MhIs within standard cancer care. MATERIALS & METHOD: Cancer HPs who worked in a service where an e-MhI was available to patients, and multi-disciplinary HPs interested in supportive care, were invited to participate via email. In semi-structured phone interviews, participants' views on e-MhIs were elicited. They were then presented with five model vignettes varying in local and centralised staff input, and asked to indicate their preference and views on each. A thematic analysis was applied to the data. RESULTS: Twelve nurses, nine psychologists, seven social workers, and three oncologists participated. Four key themes were identified: looking after patients, relationships and multidisciplinary care, trust, and feasibility, all contributing to a meta-theme of tension. Participants were motivated to ensure optimal patient outcomes and thus needed to trust the intervention content and process. They believed personal relationships increased patient engagement while affording greater work satisfaction for HPs. Most participants preferred a fully integrated model of care involving local HP assessment and design of a tailored therapy incorporating some e-MhI components where appropriate, but recognised this gold standard was likely not feasible given current resources. DISCUSSION AND CONCLUSION: Co-design with local staff of optimal models of care for the content and process of implementing e-MhIs is required, with due consideration of the patient group, staffing levels, local workflows and HP preferences, to ensure sustainability and optimal patient outcomes. CLINICAL TRIAL REGISTRATION: The ADAPT Cluster RCT is registered with the ANZCTR Registration number: ACTRN12617000411347.

Staff perspectives on the feasibility of a clinical pathway for anxiety and depression in cancer care, and mid-implementation adaptations.

BACKGROUND: Clinical pathways (CPs) are intended to standardise and improve care but do not always produce positive outcomes, possibly because they were not adapted to suit the specific context in which they were enacted. This qualitative study aimed to explore staff perspectives of implementation of a CP for routine screening, assessment, referral and management of anxiety and depression (the ADAPT CP) for patients with cancer, focussing on perceived feasibility of the CP and negotiated adaptations made during the implementation phase. METHODS: The ADAPT CP was implemented in 12 urban and regional oncology services in Australia. Services were randomised to receive core versus enhanced implementation strategies. Core sites received support until implementation commencement and could access progress reports. Enhanced sites received proactive, ongoing support during the 12-month implementation. Purposively selected staff were interviewed prior to implementation (n = 88) and 6 months later, half-way through the implementation period (n = 89). Monthly meetings with lead multi-disciplinary teams at the eight enhanced sites were recorded. Data were thematically analysed. RESULTS: Six overarching themes were identified: ADAPT is of high value; timing for introducing the CP and screening is difficult; online screening is challenging; a burden too much; no-one to refer patients to; and micro-logistics are key. While early screening was deemed desirable, diverse barriers meant this was complex, with adaptations made to time and screening location. Online screening prompted by email, seen as time-saving and efficient, also proved unsuccessful in some services, with adaptations made to in-clinic or phone screening, or repeated email reminders. Staff negative attitudes to ADAPT, time constraints, and perceived poor fit of ADAPT to work roles and flows, all impacted implementation, with key tasks often devolving to a few key individuals. Nevertheless, services remained committed to the ADAPT CP, and worked hard to create, review and adapt strategies to address challenges to optimise success. CONCLUSIONS: This study demonstrates the interactive nature of health service change, with staff actively engaging with, forming views on, and problem-solving adaptations of the ADAPT CP to overcome barriers. Obtaining staff feedback is critical to ensure health service change is sustainable, meaningful and achieves its promise of improving patient outcomes. TRIAL REGISTRATION: The study was registered prospectively with the ANZCTR on 22/3/2017. Trial ID ACTRN12617000411347.

Doctors' Attitudes to Patient Question Asking, Patient-Generated Question Lists, and Question Prompt Lists: A Qualitative Study.

BACKGROUND: Participation by patients in their own health care improves quality and safety. Question prompt lists (QPLs) can improve participation, particularly with doctors' endorsement. Few data have explored doctors' attitudes on these tools. We sought the experiences and attitudes of general practitioners and other specialists toward patient question asking and QPLs in their practice. METHODS: In-depth, semistructured interviews and focus groups with purposively selected Australian doctors were conducted. Interview guides were used to explore doctors' experiences of patient question asking, patients' lists, and a sample QPL created using an Australian government-funded online tool, "Question Builder." Recordings were transcribed verbatim and data analyzed thematically using the method by Braun and Clarke. RESULTS: Focus groups with 3 to 9 participants and a further 17 individual interviews were conducted. There was a total of 40 participants, 23 general practitioners and 17 other specialists (e.g., physicians, surgeons, pediatricians). Our analysis was summarized into several themes. 1) The doctors expected, encouraged, and had significant experience of patient question asking and patients' lists. They described many barriers for patients and their efforts to ensure patients had the information they needed. 2) The doctors felt responsible for creating an environment conducive to patient question asking, the delivery of answers, having strategies for unanswered questions, and balancing the agendas of both parties in the consultation. 3) Structured QPLs that prepared patients and facilitated the consultation agenda were viewed positively. The degree of time pressures participating doctors experienced in their context had a strong influence on how they responded to the sample QPL. CONCLUSION: Doctors in this study expected patients to ask questions and endorsed the benefits of QPLs. However, there were more diverse views about the feasibility of implementing them in practice. Designing QPLs to fit within current workflows, via more succinct and tailored designs, may result in wider doctor acceptance and endorsement, hence maximizing the benefits of QPLs with improved patient participation and patient safety.

A feasibility study of a best practice health literacy app for Australian adults with chronic kidney disease.

Objective: To investigate feasibility of the SUCCESS app; a cross-platform e-health innovation to improve health literacy, self-management and shared decision-making among culturally-diverse Australian haemodialysis patients. Methods: Multi-site, pre-post, mixed-methods study. Haemodialysis patients ≥18 years used the app for 12 weeks. Qualitative data from 18 interviews were thematically analysed to evaluate app acceptability. Quantitative analysis using paired sampled t-tests evaluated feasibility outcomes pertaining to recruitment, retention, data collection and app efficacy (including health literacy; decision self-efficacy; quality of life; behaviour; knowledge; confidence). Results: We successfully recruited diverse participants (N = 116; 45% born overseas; 40% low/moderate health literacy) from four Local Health Districts in Sydney, Australia. However, only 61 participants completed follow-up questionnaires. Qualitative analyses provided insights into acceptability and user engagement. Quantitative analyses showed significant improvements on the health literacy domain 'Ability to actively engage with healthcare providers' (Mean Difference [MD] = 0.2 on a 5-point scale; CI95%: 0.0-0.4; p = 0.03) and decision self-efficacy (MD = 4.3 on a 10-point scale; CI95%: 0.6-7.9; p = 0.02) after 12 weeks app use. Conclusions: The SUCCESS app was feasible and acceptable to participants. The app will be adapted to facilitate ongoing use and engagement among diverse haemodialysis patients. Innovation: This is the first health literacy-informed app to promote active participation in haemodialysis self-management and decision-making, tailored toward culturally-diverse and low health literacy groups.

Acceptability and appropriateness of a clinical pathway for managing anxiety and depression in cancer patients: a mixed methods study of staff perspectives.

BACKGROUND: Clinical pathways (CPs) can improve health outcomes, but to be sustainable, must be deemed acceptable and appropriate by staff. A CP for screening and management of anxiety and depression in cancer patients (the ADAPT CP) was implemented in 12 Australian oncology services for 12 months, within a cluster randomised controlled trial of core versus enhanced implementation strategies. This paper compares staff-perceived acceptability and appropriateness of the ADAPT CP across study arms. METHODS: Multi-disciplinary lead teams at each service tailored, planned, championed and implemented the CP. Staff at participating services, purposively selected for diversity, completed a survey and participated in an interview prior to implementation (T0), and at midpoint (6 months: T1) and end (12 months: T2) of implementation. Interviews were recorded, transcribed and thematically analysed. RESULTS: Seven metropolitan and 5 regional services participated. Questionnaires were completed by 106, 58 and 57 staff at T0, T1 and T2 respectively. Eighty-eight staff consented to be interviewed at T0, with 89 and 76 at T1 and T2 (response rates 70%, 66% and 57%, respectively). Acceptability/appropriateness, on the quantitative measure, was high at T0 (mean of 31/35) and remained at that level throughout the study, with no differences between staff from core versus enhanced services. Perceived burden was relatively low (mean of 11/20) with no change over time. Lowest scores and greatest variability pertained to perceived impact on workload, time and cost. Four major themes were identified: 1) Mental health is an important issue which ADAPT addresses; 2) ADAPT helps staff deliver best care, and reduces staff stress; 3) ADAPT is fit for purpose, for both cancer care services and patients; 4) ADAPT: a catalyst for change. Opposing viewpoints are outlined. CONCLUSIONS: This study demonstrated high staff-perceived acceptability and appropriateness of the ADAPT CP with regards to its focus, evidence-base, utility to staff and patients, and ability to create change. However, concerns remained regarding burden on staff and time commitment. Strategies from a policy and managerial level will likely be required to overcome the latter issues. TRIAL REGISTRATION: The study was registered prospectively with the ANZCTR on 22/3/2017. Trial ID ACTRN12617000411347. https://www.anzctr.org.au/ .

Providing Balanced Information about Options in Patient Decision Aids: An Update from the International Patient Decision Aid Standards.

BACKGROUND: The objective of this International Patient Decision Aids Standard (IPDAS) review is to update and synthesize theoretical and empirical evidence on how balanced information can be presented and measured in patient decision aids (PtDAs). METHODS: A multidisciplinary team conducted a scoping review using 2 search strategies in multiple electronic databases evaluating the ways investigators defined and measured the balance of information provided about options in PtDAs. The first strategy combined a search informed by the Cochrane Review of the Effectiveness of Decision Aids with a search on balanced information. The second strategy repeated the search published in the 2013 IPDAS update on balanced presentation. RESULTS: Of 2450 unique citations reviewed, the full text of 168 articles was screened for eligibility. Sixty-four articles were included in the review, of which 13 provided definitions of balanced presentation, 8 evaluated mechanisms that may introduce bias, and 42 quantitatively measured balanced with methods consistent with the IPDAS criteria in PtDAs. The revised definition of balanced information is, "Objective, complete, salient, transparent, evidence-informed, and unbiased presentation of text and visual information about the condition and all relevant options (with important elements including the features, benefits, harms and procedures of those options) in a way that does not favor one option over another and enables individuals to focus attention on important elements and process this information." CONCLUSIONS: Developers can increase the balance of information in PtDAs by informing their structure and design elements using the IPDAS checklist. We suggest that new PtDA components pertaining to balance be evaluated for cognitive bias with experimental methods as well by objectively evaluating patients' and content experts' beliefs from multiple perspectives.

Impact of Individual, Organizational, and Technological Factors on the Implementation of an Online Portal to Support a Clinical Pathway Addressing Psycho-Oncology Care: Mixed Methods Study.

BACKGROUND: Clinical pathways (CPs) can improve patient outcomes but can be complex to implement. Technologies, such as clinical decision support (CDS) tools, can facilitate their use, but require end-user testing in clinical settings. OBJECTIVE: This study applied the Technology Acceptance Model to evaluate the individual, organizational, and technological contexts impacting application of a portal to facilitate a CP for anxiety and depression (the ADAPT Portal) in a metropolitan cancer service. The ADAPT Portal triggers patient screening on patient reported outcomes, alerts staff to high scores, recommends evidence-based management, and triggers review and rescreening at set intervals. METHODS: Quantitative and qualitative data on portal activity, data accuracy, and health service staff perspectives were collected. Quantitative data were analyzed descriptively, and thematic analysis was applied to qualitative data. RESULTS: Overall, 15 (100% of those invited) health service staff agreed to be interviewed. During the pilot, 73 users (36 health service staff members and 37 patients) were registered on the ADAPT Portal. Of the 37 patients registered, 16 (43%) completed screening at least once, with seven screening positive and triaged appropriately. In total, 34 support requests were lodged, resulting in 17 portal enhancements (technical issues). Health service staff considered the ADAPT Portal easy to use and useful; however, some deemed it unnecessary or burdensome (individual issues), particularly in a busy cancer service (organizational issues). CONCLUSIONS: User testing of a CDS to facilitate screening and assessment of anxiety and depression in cancer patients highlighted some technological issues in implementing the ADAPT CDS, resulting in 17 enhancements. Our results highlight the importance of obtaining health service staff feedback when piloting specialized CDS tools and addressing contextual factors when implementing them.

Assessment of an evidence-based laryngeal cancer fact sheet: A mixed methods study.

To evaluate perceptions of a laryngeal cancer fact sheet amongst people with direct experience of the disease and its treatment. A mixed methods study (questionnaire and interview) evaluating the information resource was conducted across two institutions. In total 20 participants responded to the questionnaire. Overall participants reported the information resource was detailed and understandable. Insufficient information was provided on: impact on family in eight participants (40%); impact on work in six (33%); and, second opinions and long-term side effects in five (25%). The majority (67%) wanted a large amount of information with the preferred source being one-on-one meetings with their doctor. The thematic analysis identified three main themes: preferences for information, self-management; and, information sources. People with direct experience of laryngeal cancer and its treatments reported the information resource was comprehensive and clear. There were some gaps in the information provided, particularly related to survivorship issues.

Health Literacy and Shared Decision-making: Exploring the Relationship to Enable Meaningful Patient Engagement in Healthcare.

Research into health literacy and shared decision-making has largely developed along parallel, but distinct lines over the past two decades. There is little evidence that the concepts and related practice have intersected except in the most functional way, for example, to simplify shared decision-making tools by improving readability scores of decision aids. This paper presents an integrated model to strengthen and sustain patient engagement in health care by drawing on the strengths of both concepts. This includes addressing patients' skills and capacities, alongside modifications to written and verbal information. We propose an expanded model of shared decision-making which incorporates health literacy concepts and promotes two-tiered intervention methods to improve the targeting and personalization of communication and support the development of transferable health literacy skills among patients.