Communicating the Imperfect Diagnostic Accuracy of COVID-19 Rapid Antigen Self-Tests: An Online Randomized Experiment.

OBJECTIVE: To investigate the potential impacts of optimizing coronavirus disease 2019 (COVID-19) rapid antigen test (RAT) self-testing diagnostic accuracy information. DESIGN: Online randomized experiment using hypothetical scenarios: in scenarios 1 to 3 (RAT result positive), the posttest probability was considered to be very high (likely true positives), and in scenarios 4 and 5 (RAT result negative), the posttest probability was considered to be moderately high (likely false negatives). SETTING: December 12 to 22, 2022, during the mixed-variant Omicron wave in Australia. PARTICIPANTS: Australian adults. Intervention: diagnostic accuracy of a COVID-19 self-RAT presented in a health literacy-sensitive way; usual care: diagnostic accuracy information provided by the manufacturer; control: no diagnostic accuracy information. MAIN OUTCOME MEASURE: Intention to self-isolate. RESULTS: A total of 226 participants were randomized (control n = 75, usual care n = 76, intervention n = 75). More participants in the intervention group correctly interpreted the meaning of the diagnostic accuracy information (P = 0.08 for understanding sensitivity, P < 0.001 for understanding specificity). The proportion who would self-isolate was similar across scenarios 1 to 3 (likely true positives). The proportion was higher in the intervention group than in the control for scenarios 4 and 5 (likely false negatives). These differences were not statistically significant. The largest potential effect was seen in scenario 5 (dinner party with confirmed cases, the person has symptoms, negative self-RAT result), with 63% of the intervention group and 49% of the control group indicating they would self-isolate (absolute difference 13.3%, 95% confidence interval: -2% to 30%, P = 0.10). CONCLUSION: Health literacy sensitive formatting supported participant understanding and recall of diagnostic accuracy information. This may increase community intentions to self-isolate when there is a likely false-negative self-RAT result. Trial registration: Australia New Zealand Clinical Trial Registry (ACTRN12622001517763). HIGHLIGHTS: Community-based diagnostic accuracy studies of COVID-19 self-RATs indicate substantially lower sensitivity (and higher risk of false-negative results) than the manufacturer-supplied information on most government public Web sites.This online randomized study found that a health literacy-sensitive presentation of the imperfect diagnostic accuracy COVID-19 self-RATs supported participant understanding and recall of diagnostic accuracy information.Health literacy-sensitive presentation may increase community intentions to self-isolate after a negative test result where the posttest probability is still moderately high (i.e., likely false-negative result).To prevent the onward spread of infection, efforts to improve communication about the high risk of false-negative results from COVID-19 self-RATs are urgently needed.

How do general practitioners manage patient health literacy differences in cardiovascular disease prevention consultations? An interview study.

OBJECTIVES: Low health literacy is associated with worse health outcomes, including for cardiovascular disease (CVD). However, general practitioners (GPs) have limited support to identify and address patient health literacy needs in CVD prevention consultations. This study explored GPs' experiences of patient health literacy needs during CVD risk assessment and management consultations. METHODS: Semi-structured interviews with 18 GPs in Tasmania, Australia in 2021. A Framework Analysis approach was used to code transcripts to a thematic framework. RESULTS: GPs perceptions on patient health literacy informed three themes: 1. Methods of estimating health literacy; 2. GPs' perceptions about the impact of health literacy on CVD prevention including risk factor knowledge and behaviours; and 3. Strategies for communicating with patients experiencing health literacy challenges. The findings show that while no formal tools were used to assess health literacy in this sample, perceived health literacy can change GPs' communication and prevention strategies. CONCLUSION: The findings raise concerns about the equity of choices made available to patients, based on subjective perceptions of their health literacy level. PRACTICE IMPLICATION: GPs could be better supported to assess and address patient health literacy needs in CVD prevention consultations.

Could nudges reduce health literacy disparities in CVD prevention? An experiment using alternative messages for CVD risk assessment screening.

OBJECTIVE: To explore the effect of SMS nudge messages amongst people with varying health literacy on their intention to get a Heart Health Check. METHODS: A 3 (Initial SMS: scarcity, regret, or control nudge) x 2 (Reminder SMS: social norm or control nudge) factorial design was used in a hypothetical online experiment. 705 participants eligible for Heart Health Checks were recruited. Outcomes included intention to attend a Heart Health Check and psychological responses. RESULTS: In the control condition, people with lower health literacy had lower behavioural intentions compared to those with higher health literacy (p = .011). Scarcity and regret nudges closed this gap, resulting in similar intention levels for lower and higher health literacy. There was no interactive effect of the reminder nudge and health literacy (p = .724). CONCLUSION: Scarcity and regret nudge messages closed the health literacy gap in behavioural intentions compared to a control message, while a reminder nudge had limited additional benefit. Health literacy should be considered in behavioural intervention evaluations to ensure health equity is addressed. PRACTICE IMPLICATIONS: Results informed a national screening program using a universal precautions approach, where messages with higher engagement for lower health literacy groups were used in clinical practice.

Qualitative and Quantitative Evaluation of an Innovative Primary and Secondary Diabetes Clinic in Western Sydney.

Introduction: Western Sydney Diabetes (WSD) established an innovative diabetes service in May 2020, using virtual and in-person care, linking primary care with the diabetes specialist team. This study evaluated the service's feasibility using qualitative and quantitative methods. Method: Evaluation included: 1) thematic analysis of interviews and workshops with patients and health professionals (n = 28); 2) quantitative analysis of records of patients admitted July 2020-June 2021 (n = 110). Results: Key themes related to 1) benefits: convenient location, access to integrated care, advantages of virtual care; 2) challenges: hard for patients to ask questions, technology issues; 3) confidence: shared care decision making, multidisciplinary team; and 4) future directions: additional multidisciplinary services, expanded insulin stabilisation service, promotion.Improvements between baseline and 3 months included 1.3% reduction in HbA1c (p < 0.05). Sulfonylurea dropped by 25% between initial appointment and follow-up, and GLP1RA/SGLT2i use increasing by 30% (p < 0.05). The clinic covered costs using Medicare billings and Nationally Weighted Activity Units. Discussion: The findings suggest this integrated care model was feasible and perceived as beneficial by both patients and providers. The clinic offers a promising model of practice that could be developed further to roll out in other regions for rural delivery of care.

Implementing decision aids for cardiovascular disease prevention: stakeholder interviews and case studies in Australian primary care.

BACKGROUND: Australian cardiovascular disease (CVD) prevention guidelines recommend absolute CVD risk assessment, but less than half of eligible patients have the required risk factors recorded due to fragmented implementation over the last decade. Co-designed decision aids for general practitioners (GPs) and consumers have been developed that improve knowledge barriers to guideline-recommended CVD risk assessment and management. This study used a stakeholder consultation process to identify and pilot test the feasibility of implementation strategies for these decision aids in Australian primary care. METHODS: This mixed methods study included: (1) stakeholder consultation to map existing implementation strategies (2018-20); (2) interviews with 29 Primary Health Network (PHN) staff from all Australian states and territories to identify new implementation opportunities (2021); (3) pilot testing the feasibility of low, medium, and high resource implementation strategies (2019-21). Framework Analysis was used for qualitative data and Google analytics provided decision support usage data over time. RESULTS: Informal stakeholder discussions indicated a need to partner with existing programs delivered by the Heart Foundation and PHNs. PHN interviews identified the importance of linking decision aids with GP education resources, quality improvement activities, and consumer-focused prevention programs. Participants highlighted the importance of integration with general practice processes, such as business models, workflows, medical records and clinical audit software. Specific implementation strategies were identified as feasible to pilot during COVID-19: (1) low resource: adding website links to local health area guidelines for clinicians and a Heart Foundation toolkit for primary care providers; (2) medium resource: presenting at GP education conferences and integrating the resources into audit and feedback reports; (3) high resource: auto-populate the risk assessment and decision aids from patient records via clinical audit software. CONCLUSIONS: This research identified a wide range of feasible strategies to implement decision aids for CVD risk assessment and management. The findings will inform the translation of new CVD guidelines in primary care. Future research will use economic evaluation to explore the added value of higher versus lower resource implementation strategies.

Participant characteristics and reasons for non-consent to health information linkage for research: experiences from the ATHENA COVID-19 study.

BACKGROUND: The linkage of primary care, hospital and other health registry data is a global goal, and a consent-based approach is often used. Understanding the attitudes of why participants take part is important, yet little is known about reasons for non-participation. The ATHENA COVID-19 feasibility study investigated: 1) health outcomes of people diagnosed with COVID-19 in Queensland, Australia through primary care health data linkage using consent, and 2) created a cohort of patients willing to be re-contacted in future to participate in clinical trials. This report describes the characteristics of participants declining to participate and reasons for non-consent. METHODS: Patients diagnosed with COVID-19 from January 1st, 2020, to December 31st, 2020, were invited to consent to having their primary healthcare data extracted from their GP into a Queensland Health database and linked to other data sets for ethically approved research. Patients were also asked to consent to future recontact for participation in clinical trials. Outcome measures were proportions of patients consenting to data extraction, permission to recontact, and reason for consent decline. RESULTS: Nine hundred and ninety-five participants were approached and 842(85%) reached a consent decision. 581(69%), 615(73%) and 629(75%) consented to data extraction, recontact, or both, respectively. Mean (range) age of consenters and non-consenters were 50.6(22-77) and 46.1(22-77) years, respectively. Adjusting for age, gender and remoteness, older participants were more likely to consent than younger (aOR 1.02, 95%CI 1.01 to 1.03). The least socio-economically disadvantaged were more likely to consent than the most disadvantaged (aOR 2.20, 95% 1.33 to 3.64). There was no difference in consent proportions regarding gender or living in more remote regions. The main reasons for non-consent were 'not interested in research' (37%), 'concerns about privacy' (15%), 'not registered with a GP' (8%) and 'too busy/no time' (7%). 'No reason' was given in 20%. CONCLUSION: Younger participants and the more socio-economically deprived are more likely to non-consent to primary care data linkage. Lack of patient interest in research, time required to participate and privacy concerns, were the most common reasons cited for non-consent. Future health care data linkage studies addressing these issues may prove helpful.

What makes an action plan "100% me"? Think aloud interviews about CVD prevention tools for varying health literacy needs.

ISSUE ADDRESSED: Health behaviour change can be difficult to maintain. Action plans can address this issue, however, there has been little qualitative research to understand how to optimise action plan interventions. This study explored how people engage with a specific type of action plan intervention, the "volitional help sheet," in a cardiovascular disease (CVD) prevention context. METHODS: Twenty adults in the target age for CVD risk assessment (45 to 74 years) with varying health literacy participated in interviews and created an action plan to change their behaviour. Transcripts were analysed using framework analysis. RESULTS: Participants described how engagement with plans was related to how personally relevant the target behaviour and the options within the plan were. Also important was participants visualising themselves enacting the plan when deciding which option to choose. Amongst participants who already engaged in a target behaviour, some did not perceive the plan was useful; others perceived the plan as a helpful prompt or a formalisation of existing plans. For some, the barriers to behaviour change were out of the scope of an action plan, highlighting the need for alternative supports. CONCLUSION: This study provides qualitative insights into unanticipated ways that people with varying health literacy use action plans, providing new guidance for future developers. SO WHAT?: Not all action plans are created equal. Careful selection of behavioural targets and plan options and encouraging users to imagine the plan may enhance user engagement. Alternative behaviour change strategies should be available if key barriers cannot be addressed by the plan.

Twitch Data in Health Promotion Research: Protocol for a Case Study Exploring COVID-19 Vaccination Views Among Young People.

BACKGROUND: Social media platforms have emerged as a useful channel for health promotion communication, offering different channels to reach targeted populations. For example, social media has recently been used to disseminate information about COVID-19 vaccination across various demographics. Traditional modes of health communication such as television, health events, and newsletters may not reach all groups within a community. Health communications for younger generations are increasingly disseminated through social media to reflect key information sources. This paper explores a social media gaming platform as an alternative way to reach young people in health promotion research. OBJECTIVE: This protocol study aimed to pilot-test the potential of Twitch, a live streaming platform initially designed for video gaming, to conduct health promotion research with young people. We used COVID-19 vaccination as a topical case study that was recommended by Australian health authorities at the time of the research. METHODS: The research team worked with a Twitch Account Manager to design and test a case study within the guidelines and ethics protocols required by Twitch, identify suitable streamers to approach and establish a protocol for conducting research on the platform. This involved conducting a poll to initiate discussion about COVID-19 vaccination, monitoring the chat in 3 live Twitch sessions with 2 streamers to pilot the protocol, and briefly analyze Twitch chat logs to observe the range of response types that may be acquired from this methodology. RESULTS: The Twitch streams provided logs and videos on demand that were derived from the live session. These included demographics of viewers, chat logs, and polling results. The results of the poll showed a range of engagement in health promotion for the case study topic: the majority of participants had received their vaccination by the time of the poll; however, there was still a proportion that had not received their vaccination yet or had decided to not be vaccinated. Analysis of the Twitch chat logs demonstrated a range of both positive and negative themes regarding health promotion for the case study topic. This included irrelevant comments, misinformation (compared to health authority information at the time of this study), comedic and conspiracy responses, as well as vaccine status, provaccine comments, and vaccine-hesitant comments. CONCLUSIONS: This study developed and tested a protocol for using Twitch data for health promotion research with young people. With live polling, open text discussion between participants and immediate responses to questions, Twitch can be used to collect both quantitative and qualitative research data from demographics that use social media. The platform also presents some challenges when engaging with independent streamers and sensitive health topics. This study provides an initial protocol for future researchers to use and build on. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/48641.

Feasibility of a text-mediated recall system to increase cardiovascular disease risk assessment in general practice: Mixed-methods pilot evaluation.

BACKGROUND AND OBJECTIVES: The uptake of formal cardiovascular disease risk assessment in the primary prevention setting is low. We tested the feasibility of an SMS recall system to invite eligible patients for a Heart Health Check in Australian general practice. METHOD: Of 332 general practices that expressed interest in the study, 231 were randomised to either an intervention or wait list control group. Intervention general practices sent SMS invitations linked to digital information to eligible patients via general practice software. Deidentified baseline and two-month data were extracted via clinical audit software. A survey was administered to 35 intervention general practices. RESULTS: General practice visits were similar between the control and intervention groups, but Heart Health Check billing increased 14-fold in the intervention group. DISCUSSION: This study showed that an SMS recall system for Heart Health Checks can be effective and acceptable in general practice. The findings will inform a broader implementation trial over 2022-23.

Helping patient educators meet health literacy needs: End-user testing and iterative development of an innovative health literacy editing tool.

Objective: The Sydney Health Literacy Lab (SHeLL) Editor is an online text-editing tool that provides real-time assessment and feedback on written health information (assesses grade reading score, complex language, passive voice). This study aimed to explore how the design could be further enhanced to help health information providers interpret and act on automated feedback. Methods: The prototype was iteratively refined across four rounds of user-testing with health services staff (N = 20). Participants took part in online interviews and a brief follow-up survey using validated usability scales (System Usability Scale, Technology Acceptance Model). After each round, Yardley's (2021) optimisation criteria guided which changes would be implemented. Results: Participants rated the Editor as having adequate usability (M = 82.8 out of 100, SD = 13.5). Most modifications sought to reduce information overload (e.g. simplifying instructions for new users) or make feedback motivating and actionable (e.g. using frequent incremental feedback to highlight changes to the text altered assessment scores). Conclusion: terative user-testing was critical to balancing academic values and the practical needs of the Editor's target users. The final version emphasises actionable real-time feedback and not just assessment. Innovation: The Editor is a new tool that will help health information providers apply health literacy principles to written text.

Addressing Behavioral Barriers to COVID-19 Testing With Health Literacy-Sensitive eHealth Interventions: Results From 2 National Surveys and 2 Randomized Experiments.

BACKGROUND: Polymerase chain reaction (PCR) testing for COVID-19 was crucial in Australia's prevention strategy in the first 2 years of the pandemic, including required testing for symptoms, contact with cases, travel, and certain professions. However, several months into the pandemic, half of Australians were still not getting tested for respiratory symptoms, and little was known about the drivers of and barriers to COVID-19 PCR testing as a novel behavior at that time. OBJECTIVE: We aimed to identify and address COVID-19 testing barriers, and test the effectiveness of multiple eHealth interventions on knowledge for people with varying health literacy levels. METHODS: The intervention was developed in 4 phases. Phase 1 was a national survey conducted in June 2020 (n=1369), in which testing barriers were coded using the capability-opportunity-motivation-behavior framework. Phase 2 was a national survey conducted in November 2020 (n=2034) to estimate the prevalence of testing barriers and health literacy disparities. Phase 3 was a randomized experiment testing health literacy-sensitive written information for a wide range of barriers between February and March 2021 (n=1314), in which participants chose their top 3 barriers to testing to view a tailored intervention. Phase 4 was a randomized experiment testing 2 audio-visual interventions addressing common testing barriers for people with lower health literacy in November 2021, targeting young adults as a key group endorsing misinformation (n=1527). RESULTS: In phase 1, barriers were identified in all 3 categories: capability (eg, understanding which symptoms to test for), opportunity (eg, not being able to access a PCR test), and motivation (eg, not believing the symptoms are those of COVID-19). Phase 2 identified knowledge gaps for people with lower versus higher health literacy. Phase 3 found no differences between the intervention (health literacy-sensitive text for top 3 barriers) and control groups. Phase 4 showed that a fact-based animation or a TikTok-style video presenting the same facts in a humorous style increased knowledge about COVID-19 testing compared with government information. However, no differences were found for COVID-19 testing intentions. CONCLUSIONS: This study identified a wide range of barriers to a novel testing behavior, PCR testing for COVID-19. These barriers were prevalent even in a health system where COVID-19 testing was free and widely available. We showed that key capability barriers, such as knowledge gaps, can be improved with simple videos targeting people with lower health literacy. Additional behavior change strategies are required to address motivational issues to support testing uptake. Future research will explore health literacy strategies in the current context of self-administered rapid antigen tests. The findings may inform planning for future COVID-19 variant outbreaks and new public health emergencies where novel testing behaviors are required. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12621000876897, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=382318 ; Australian New Zealand Clinical Trials Registry ACTRN12620001355965, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380916&isReview=true.

Implementing patient decision aids into general practice clinical decision support systems: Feasibility study in cardiovascular disease prevention.

Objective: Patient decision aids (DA) facilitate shared decision making, but implementation remains a challenge. This study tested the feasibility of integrating a cardiovascular disease (CVD) prevention DA into general practice software. Methods: We developed a desktop computer application (app) to auto-populate a CVD prevention DA from general practice medical records. 4 practices received monthly practice reports from July-Nov 2021, and 2 practices use the app with limited engagement. CVD risk assessment data and app use were monitored. Results: The proportion of eligible patients with complete CVD risk assessment data ranged from 59 to 94%. Monthly app use ranged from 0 to 285 sessions by 13 individual practice staff including GPs and nurses, with staff using the app an average of 67 sessions during the study period. High users in the 5-month study period continued to use the app for 10 months. Low use was attributed to reduced staff capacity during COVID-19 and technical issues. Conclusion: High users sustained interest in the app, but additional strategies are required for low users. The study will inform implementation plans for new guidelines. Innovation: This study showed it is feasible to integrate patient decision aids with Australian general practice software, despite the challenges of COVID-19 at the time of the study.

Uptake of the Australian Heart Health Check before and after the COVID-19 pandemic outbreak.

BACKGROUND AND OBJECTIVES: In 2019, a 'Heart Health Check' Medicare Benefit Schedule (MBS) item (699) was introduced to support cardiovascular risk assessment. This study sought to determine the uptake of Item 699 and changes to existing health assessment item claims, before and after the COVID­19 outbreak. METHOD: National MBS data for health assessment items were analysed for adults aged ≥35 years. RESULTS: Item 699 accounted for 9% of health assessment item claims since its introduction. Claims for pre-existing health assessment items were virtually unchanged (1% increase) after Item 699 was introduced. Overall, there were 68,967 fewer health assessment item claims (7% decrease) after the COVID-19 outbreak and Item 699 had the greatest decline in claims (27% reduction). DISCUSSION: Uptake of Item 699 accounted for 9% of health assessment item claims since its introduction. COVID-19 restrictions coincided with a decline in all health assessment item claims, particularly for Item 699.

Integrating consumer perspectives into a large-scale health literacy audit of health information materials: learnings and next steps.

BACKGROUND: Health information is less effective when it does not meet the health literacy needs of its consumers. For health organisations, assessing the appropriateness of their existing health information resources is a key step to addressing this issue. This study describes novel methods for a consumer-centred large-scale health literacy audit of existing resources and reflects on opportunities to further refine the method. METHODS: This audit focused on resources developed by NPS MedicineWise, an Australian not-for-profit that promotes safe and informed use of medicines. The audit comprised 4 stages, with consumers engaged at each stage: 1) Select a sample of resources for assessment; 2) Assess the sample using subjective (Patient Education Materials Assessment Tool) and objective (Sydney Health Literacy Lab Health Literacy Editor) assessment tools; 3) Review audit findings through workshops and identify priority areas for future work; 4) Reflect and gather feedback on the audit process via interviews. RESULTS: Of 147 resources, consumers selected 49 for detailed assessment that covered a range of health topics, health literacy skills, and formats, and which had varied web usage. Overall, 42 resources (85.7%) were assessed as easy to understand, but only 26 (53.1%) as easy to act on. A typical text was written at a grade 12 reading level and used the passive voice 6 times. About one in five words in a typical text were considered complex (19%). Workshops identified three key areas for action: make resources easier to understand and act on; consider the readers' context, needs, and skills; and improve inclusiveness and representation. Interviews with workshop attendees highlighted that audit methods could be further improved by setting clear expectations about the project rationale, objectives, and consumer roles; providing consumers with a simpler subjective health literacy assessment tool, and addressing issues related to diverse representation. CONCLUSIONS: This audit yielded valuable consumer-centred priorities for improving organisational health literacy with regards to updating a large existing database of health information resources. We also identified important opportunities to further refine the process. Study findings provide valuable practical insights that can inform organisational health actions for the upcoming Australian National Health Literacy Strategy.

COVID-19 messages targeting young people on social media: content analysis of Australian health authority posts.

Health authorities utilized social media during the COVID-19 pandemic to disseminate critical and timely health messages, specifically targeting priority groups such as young people. To understand how social media was used for this purpose, we investigated the content of COVID-19-related social media posts targeting young people (16-29 years old) shared by Australian health departments. Posts targeting young people with COVID-19 information were extracted from all eight Australian State and Territory health department Facebook, Instagram and TikTok accounts over 1 month of the Delta outbreak (September 2021) and analysed thematically. In total, 238 posts targeting young people were identified from 1059 COVID-19 posts extracted. All eight health departments used Facebook, five used Instagram and only one used TikTok. The majority of posts implicitly targeted young people; only 14.7% explicitly mentioned age or 'young people'. All posts included accompanying visuals; 77% were still images like photos or illustrations whilst 23% were moving images like videos and GIFs. Communication techniques included calls to action (63% of posts), responsive communication (32% of posts) and positive emotional appeal (31% of posts). Social marketing techniques catering to young people were used to varying extents despite receiving higher levels of engagement; 45% featured emojis whilst only 16% used humour, 14% featured celebrities and 6% were memes. Priority groups like ethnic/cultural groups and chronic health/disability communities were rarely targeted in this communication. The findings indicate a lack of health communication on social media directed towards young people, highlighting an opportunity for increased use of platforms like TikTok and trends popular with young people online.

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.

Supporting conversations about medicines and deprescribing: GPs' perspectives on a Medicines Conversation Guide.

OBJECTIVES: To explore GP perspectives on a Medicines Conversation Guide to support deprescribing communication. METHODS: Semistructured interviews with GPs from Australia (n = 32). Participants were purposively sampled with varying experiences and locations. Transcribed audio recordings of interviews were coded using framework analysis. KEY FINDINGS: Most GPs stated they would use the Guide in consultation with an older patient to discuss medications. The strengths of the Guide included empowering the patient voice on an important topic. Limitations included time and complex concepts. CONCLUSIONS: Overall, the Medicines Conversation Guide was perceived by GPs to be a useful communication tool to support discussions about deprescribing with patients.

Biological age calculators to motivate lifestyle change: Environmental scan of online tools and evaluation of behaviour change techniques.

OBJECTIVE: "Biological age" calculators are widely used as a way of communicating health risk. This study evaluated the behaviour change techniques (BCTs) within such tools, underlying algorithm differences and suitability for people with varying health literacy. METHODS: Two authors entered terms into Google (eg, biological/heart age) and recorded the first 50 results. A standard patient profile was entered into eligible biological age calculators. Evaluation was based on Michie et al's BCT taxonomy and a readability calculator. RESULTS: From 4000 search results, 20 calculators were identified: 11 for cardiovascular age, 7 for general biological age and 2 for fitness age. The calculators gave variable results for the same 65-year-old profile: biological age ranged from younger to older (57-87 years), while heart age was always older (69-85+ years). Only 11/20 (55%) provided a reference explaining the underlying algorithm. The average reading level was Grade 10 (range 8.7-12.4; SD 1.44). The most common BCTs were salience of consequences, information about health consequences and credible source. CONCLUSIONS: Biological age tools have highly variable results, BCTs and readability. PRACTICE IMPLICATIONS: Developers are advised to use validated models, explain the result at the average Grade 8 reading level, and incorporate a clear call to action using evidence-based behaviour change techniques.

Collateral positives of COVID-19 for culturally and linguistically diverse communities in Western Sydney, Australia.

BACKGROUND: To investigate whether culturally and linguistically diverse (CALD) communities in Western Sydney have experienced any positive effects during the COVID-19 pandemic, and if so, what these were. METHODS: A cross-sectional survey with ten language groups was conducted from 21st March to 9th July 2021 in Sydney, Australia. Participants were recruited through bilingual multicultural health staff and health care interpreter service staff and answered a question, 'In your life, have you experienced any positive effects from the COVID-19 pandemic?' Differences were explored by demographic variables. Free-text responses were thematically coded using the Content Analysis method. RESULTS: 707 people completed the survey, aged 18 to >70, 49% males and 51% females. Only 161 (23%) of those surveyed reported any positive impacts. There were significant differences in the proportion of those who reported positives based on age (p = 0.004), gender (p = 0.013), language (p = 0.003), health literacy (p = 0.014), English language proficiency (p = 0.003), education (p = <0.001) and whether participants had children less than 18 years at home (p = 0.001). Content Analysis of open-ended responses showed that, of those that did report positives, the top themes were 'Family time' (44%), 'Improved self-care' (31%) and, 'Greater connection with others' (17%). DISCUSSION: Few surveyed participants reported finding any positives stemming from the COVID-19 pandemic. This finding is in stark contrast to related research in Australia with participants whose native language is English in which many more people experienced positives. The needs of people from CALD backgrounds must inform future responses to community crises to facilitate an equitable effect of any collateral positives that may arise.

Testing behaviour may bias observational studies of vaccine effectiveness.

BACKGROUND: Recent observational studies suggest that vaccines may have little effect in preventing infection with the Omicron variant of severe acute respiratory syndrome coronavirus 2. However, the observed effects may be confounded by patient factors, preventive behaviours, or differences in testing behaviour. To assess potential confounding, we examined differences in testing behaviour between unvaccinated and vaccinated populations. METHODS: We recruited 1,526 Australian adults for an online randomized study about coronavirus disease 2019 (COVID-19) testing in late 2021, collecting self-reported vaccination status and three measures of COVID-19 testing behaviour: testing in past month or ever and test intention if they woke with a sore throat. We examined the association between testing intentions and vaccination status in the trial's baseline data. RESULTS: Of the 1,526 participants (mean age 31 y), 22% had a COVID-19 test in the past month and 61% ever; 17% were unvaccinated, 11% were partially vaccinated (one dose), and 71% were fully vaccinated (two or more doses). Fully vaccinated participants were twice as likely as those who were unvaccinated (relative risk [RR] 2.2, 95% CI 1.8 to 2.8, p < 0.001) to report positive COVID testing intentions. Partially vaccinated participants had less positive intentions than fully vaccinated participants (RR 0.68, 95% CI 0.52 to 0.89, p < 0.001) but higher intentions than unvaccinated participants (RR 1.5, 95% CI 1.4 to 1.6, p = 0.002). DISCUSSION: Vaccination predicted greater COVID-19 testing intentions and would substantially bias observed vaccine effectiveness. To account for differential testing behaviours, test-negative designs are currently the preferred option, but their assumptions need more thorough examination.

HISTORIQUE: Selon de récentes études observationnelles, les vaccins peuvent avoir peu d'effet sur la prévention de l'infection par le variant Omicron du coronavirus 2 du syndrome respiratoire aigu sévère. Cependant, les effets observés peuvent être biaisés par des facteurs liés aux patients, des comportements préventifs ou des différences de comportements liés aux tests. Pour évaluer les facteurs confusionnels potentiels, les auteurs ont examiné les différences de comportements liés aux tests entre les populations non vaccinées et vaccinées. MÉTHODOLOGIE: Les auteurs ont recruté 1 526 adultes australiens en vue d'une étude randomisée en ligne sur les tests de la maladie à coronavirus 2019 (COVID-19) à la fin de 2021, afin de colliger l'état vaccinal autodéclaré et trois mesures sur les comportements liés aux tests de la COVID-19 : test au cours du mois précédent ou jamais auparavant et intention de se soumettre à un test en cas de mal de gorge. Ils ont examiné l'association entre les intentions de se soumettre à un test et l'état vaccinal dans les données de référence de l'étude. RÉSULTATS: Sur les 1 526 participants (d'un âge moyen de 31 ans), 22 % avaient subi un test de COVID-19 au cours du mois précédent et 61 % n'en avaient jamais subi; 17 % n'étaient pas vaccinés, 11 % l'étaient partiellement (une dose) et 71 % l'étaient pleinement (au moins deux doses). Les participants pleinement vaccinés étaient deux fois plus susceptibles que ceux qui ne l'étaient pas (risque relatif [RR] 2,2, IC à 95 % 1,8 à 2,8, p < 0,001) de déclarer des intentions de se faire tester contre la COVID-19. Les participants partiellement vaccinés avaient des intentions moins positives que les participants pleinement vaccinés (RR 0,68, IC à 95 % 0,52 à 0,89, p < 0,001), mais plus élevées que ceux qui ne l'étaient pas du tout (RR 1,5, IC à 95 % 1,4 à 1,6, p = 0,002). DISCUSSION: La vaccination était prédictive de plus grandes intentions de subir un test de COVID-19 et établissait un biais important à l'égard de l'efficacité réelle des vaccins. Pour tenir compte des comportements différentiels vis-à-vis des tests, les méthodologies de tests négatifs constituent actuellement la solution privilégiée, mais cette hypothèse doit être approfondie.