Cognitive bias modification to prevent depression (COPE): results of a randomised controlled trial.

BACKGROUND: Although efficacious treatments for major depression are available, efficacy is suboptimal and recurrence is common. Effective preventive strategies could reduce disability associated with the disorder, but current options are limited. Cognitive bias modification (CBM) is a novel and safe intervention that attenuates biases associated with depression. This study investigated whether the delivery of a CBM programme designed to attenuate negative cognitive biases over a period of 1 year would decrease the incidence of major depression among adults with subthreshold symptoms of depression. METHODS: Randomised double-blind controlled trial delivered an active CBM intervention or a control intervention over 52 weeks. Two hundred and two community-dwelling adults who reported subthreshold levels of depression were randomised (100 intervention, 102 control). The primary outcome of interest was the incidence of major depressive episode assessed at 11, 27 and 52 weeks. Secondary outcomes included onset of clinically significant symptoms of depression, change in severity of depression symptoms and change in cognitive biases. RESULTS: Adherence to the interventions was modest though did not differ between conditions. Incidence of major depressive episodes was low. Conditions did not differ in the incidence of major depressive episodes. Likewise, conditions did not differ in the incidence of clinically significant levels of depression, change in the severity of depression symptoms or change in cognitive biases. CONCLUSIONS: Active CBM intervention did not decrease the incidence of major depressive episodes as compared to a control intervention. However, adherence to the intervention programme was modest and the programme failed to modify the expected mechanism of action.

The effect of cancer warning statements on alcohol consumption intentions.

In response to increasing calls to introduce warning labels on alcoholic beverages, this study investigated the potential effectiveness of alcohol warning statements designed to increase awareness of the alcohol-cancer link. A national online survey was administered to a diverse sample of Australian adult drinkers (n = 1,680). Along with attitudinal, intentions and demographic items, the survey included an online simulation that exposed respondents to one of six cancer warning statements delivered across a range of situational contexts. Half of the statements made general reference to cancer and half mentioned specific forms of cancer. Respondents reported on the believability, convincingness and personal relevance of the warning statements. Pre- and post-exposure data were captured relating to respondents' alcohol consumption intentions. Of the six statements tested, Alcohol increases your risk of bowel cancer produced the highest scores across all outcome measures. All statements produced favorable changes in alcohol consumption intentions, including among high-risk drinkers. There is thus the potential for these and similar statements to be used as a suite of rotating warning messages located on alcoholic beverage labels and applied in various public education contexts.

A Comparison of Alcohol Consumption Intentions Among Pregnant Drinkers and Their Nonpregnant Peers of Child-Bearing Age.

OBJECTIVE: To investigate alcohol consumption intentions among Australian women of childbearing age by pregnancy status. METHODS: Three national online surveys were conducted with adult drinkers who consume an alcoholic beverage at least two days per month. Data from female respondents of childbearing age were analyzed according to pregnancy status: pregnant (n = 101), possibly pregnant (n = 178), and not pregnant (n = 1,957). RESULTS: Pregnant drinkers were significantly more likely than possibly pregnant and nonpregnant drinkers of child-bearing age to report that they should and will reduce their alcohol consumption. Results showed that 33% of the pregnant women, 32% of the nonpregnant women, and 39% of the possibly pregnant women reported intending to drink five or more standard drinks on a single occasion in the following two weeks. Older pregnant women exhibited higher rates of heavy drinking intentions and lower intentions to reduce their consumption relative to younger pregnant women. CONCLUSION: Despite current alcohol consumption guidelines recommending abstinence while pregnant, pregnant respondents exhibited heavy episodic drinking intentions comparable to those of their nonpregnant peers. IMPLICATIONS: There is a need to increase public awareness of current alcohol guidelines for pregnant women. Older women of childbearing age and those planning a pregnancy may require particular attention.

Developing cancer warning statements for alcoholic beverages.

BACKGROUND: There is growing evidence of the increased cancer risk associated with alcohol consumption, but this is not well understood by the general public. This study investigated the acceptability among drinkers of cancer warning statements for alcoholic beverages. METHODS: Six focus groups were conducted with Australian drinkers to develop a series of cancer-related warning statements for alcohol products. Eleven cancer warning statements and one general health warning statement were subsequently tested on 2,168 drinkers via an online survey. The statements varied by message frame (positive vs negative), cancer reference (general vs specific), and the way causality was communicated ('increases risk of cancer' vs 'can cause cancer'). RESULTS: Overall, responses to the cancer statements were neutral to favorable, indicating that they are unlikely to encounter high levels of negative reaction from the community if introduced on alcoholic beverages. Females, younger respondents, and those with higher levels of education generally found the statements to be more believable, convincing, and personally relevant. Positively framed messages, those referring to specific forms of cancer, and those using 'increases risk of cancer' performed better than negatively framed messages, those referring to cancer in general, and those using the term 'can cause cancer'. CONCLUSION: Cancer warning statements on alcoholic beverages constitute a potential means of increasing awareness about the relationship between alcohol consumption and cancer risk.

STI in remote communities: improved and enhanced primary health care (STRIVE) study protocol: a cluster randomised controlled trial comparing 'usual practice' STI care to enhanced care in remote primary health care services in Australia.

BACKGROUND: Despite two decades of interventions, rates of sexually transmissible infections (STI) in remote Australian Aboriginal communities remain unacceptably high. Routine notifications data from 2011 indicate rates of chlamydia and gonorrhoea among Aboriginal people in remote settings were 8 and 61 times higher respectively than in the non-Indigenous population. METHODS/DESIGN: STRIVE is a stepped-wedge cluster randomised trial designed to compare a sexual health quality improvement program (SHQIP) to usual STI clinical care delivered in remote primary health care services. The SHQIP is a multifaceted intervention comprising annual assessments of sexual health service delivery, implementation of a sexual health action plan, six-monthly clinical service activity data reports, regular feedback meetings with a regional coordinator, training and financial incentive payments. The trial clusters comprise either a single community or several communities grouped together based on geographic proximity and cultural ties. The primary outcomes are: prevalence of chlamydia, gonorrhoea and trichomonas in Aboriginal residents aged 16-34 years, and performance in clinical management of STIs based on best practice indicators. STRIVE will be conducted over five years comprising one and a half years of trial initiation and community consultation, three years of trial conditions, and a half year of data analysis. The trial was initiated in 68 remote Aboriginal health services in the Northern Territory, Queensland and Western Australia. DISCUSSION: STRIVE is the first cluster randomised trial in STI care in remote Aboriginal health services. The trial will provide evidence to inform future culturally appropriate STI clinical care and control strategies in communities with high STI rates. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12610000358044.

Improving rural and remote practitioners' knowledge of the diabetic foot: findings from an educational intervention.

BACKGROUND: This study aimed to determine knowledge of national guidelines for diabetic foot assessment and risk stratification by rural and remote healthcare professionals in Western Australia and their implementation in practice. Assessment of diabetic foot knowledge, availability of equipment and delivery of foot care education in a primary healthcare setting at baseline enabled evaluation of the effectiveness of a diabetic foot education and training program for generalist healthcare professionals. METHODS: This study employed a quasi-experimental pre-test/post-test study design. Healthcare practitioners' knowledge, attitudes and practice of diabetic foot assessment, diabetic foot risks, risk stratification, and use of the 2011 National Health and Medical Research Council Guidelines were investigated with an electronic pre-test survey(.) Healthcare professionals then undertook a 3-h education and training workshop before completing the electronic post-test knowledge, attitudes and practice survey. Comparison of pre-test/post-test survey findings was used to assess the change in knowledge, attitudes and intended practice due to the workshops. RESULTS: Two hundred and forty-six healthcare professionals from two rural and remote health regions of Western Australia participated in training workshops. Monofilaments and diabetes foot care education brochures, particularly brochures for Aboriginal people, were reported as not readily available in rural and remote health services. For most participants (58 %), their post-test knowledge score increased significantly from the pre-test score. Use of the Guidelines in clinical settings was low (19 %). The healthcare professionals' baseline diabetic foot knowledge was adequate to correctly identify the high risk category. However, stratification of the intermediate risk category was poor, even after training. CONCLUSION: This study reports the first assessment of Western Australia's rural and remote health professionals' knowledge, attitudes and practices regarding the diabetic foot. It shows that without training, generalists' levels of knowledge concerning the diabetic foot was low and they were unlikely to assess foot risk. The findings from this study in a rural and remote setting cast doubt on the ability of generalist healthcare professionals to stratify risk appropriately, especially for those at intermediate risk, without clinical decision support tools.

Clinical decision support software for diabetic foot risk stratification: development and formative evaluation.

BACKGROUND: Identifying people at risk of developing diabetic foot complications is a vital step in prevention programs in primary healthcare settings. Diabetic foot risk stratification systems predict foot ulceration. The aim of this study was to explore the views and experiences of potential end users during development and formative evaluations of an electronic diabetic foot risk stratification tool based on evidence-based guidelines and determine the accuracy of the tool. METHODS: Formative evaluation of the risk tool occurred in five stages over an eight-month period and employed a mixed methods research design consisting of semi-structured interviews, focus group and participant observation, online survey, expert review, comparison to the Australian Guidelines and clinical testing. RESULTS: A total of 43 healthcare practitioners trialled the computerised clinical decision support system during development, with multiple software changes made as a result of feedback. Individual and focus group participants exposed critical design flaws. Live testing revealed risk stratification errors and functional limitations providing the basis for practical improvements. In the final product, all risk calculations and recommendations made by the clinical decision support system reflect current Australian Guidelines. CONCLUSIONS: Development of the computerised clinical decision support system using evidence-based guidelines can be optimised by a multidisciplinary iterative process of feedback, testing and software adaptation by experts in modern development technologies.

Cognitive bias modification to prevent depression (COPE): study protocol for a randomised controlled trial.

BACKGROUND: Depression is a leading cause of disability worldwide and, although efficacious treatments are available, their efficacy is suboptimal and recurrence of symptoms is common. Effective preventive strategies could reduce disability and the long term social and health complications associated with the disorder, but current options are limited. Cognitive bias modification (CBM) is a novel, simple, and safe intervention that addresses attentional and interpretive biases associated with anxiety, dysphoria, and depression. The primary aim of this trial is to determine if CBM decreases the one-year onset of a major depressive episode among adults with subsyndromal depression. DESIGN AND METHODS: This randomised controlled trial will recruit 532 adults with subsyndromal symptoms of depression living in the Australian community (parallel design, 1:1 allocation ratio). Participants will be free of clinically significant symptoms of depression and of psychotic disorders, sensory and cognitive impairment, and risky alcohol use. The CBM intervention will target attentional and interpretive biases associated with depressive symptoms. The sessions will be delivered via the internet over a period of 52 weeks. The primary outcome of interest is the onset of a major depressive episode according the DSM-IV-TR criteria over a 12-month period. Secondary outcomes of interest include change in the severity of depressive symptoms as measured by the Patient Health Questionnaire (PHQ-9), use of antidepressants or benzodiazepines, and changes in attention and interpretive biases. The assessment of outcomes will take place 3, 6, 9, and 12 months after randomisation and will occur via the internet. DISCUSSION: We propose to test the efficacy of an innovative intervention that is well grounded in theory and for which increasing empirical evidence for an effect on mood is available. The intervention is simple, inexpensive, easy to access, and could be easily rolled out into practice if our findings confirm a role for CBM in the prevention of depression. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12613001334796. Date: 5th December 2013.

Statistical semantic and clinician confidence analysis for correcting abbreviations and spelling errors in clinical progress notes.

MOTIVATION: Progress notes are narrative summaries about the status of patients during the course of treatment or care. Time and efficiency pressures have ensured clinicians' continued preference for unstructured text over entering data in forms when composing progress notes. The ability to extract meaningful data from the unstructured text contained within the notes is invaluable for retrospective analysis and decision support. The automatic extraction of data from unstructured notes, however, has been largely prevented due to the complexity of handling abbreviations, misspelling, punctuation errors and other types of noise. OBJECTIVE: We present a robust system for cleaning noisy progress notes in real-time, with a focus on abbreviations and misspellings. METHODS: The system uses statistical semantic analysis based on Web data and the occasional participation of clinicians to automatically replace abbreviations with the actual senses and misspellings with the correct words. RESULTS: An accuracy of as high as 88.73% was achieved based only on statistical semantic analysis using Web data. The response time of the system with the caching mechanism enabled is 1.5-2s per word which is about the same as the average typing speed of clinicians. CONCLUSIONS: The overall accuracy and the response time of the system will improve with time, especially when the confidence mechanism is activated through clinicians' interactions with the system. This system will be implemented in a clinical information system to drive interactive decision support and analysis functions leading to improved patient care and outcomes.