Deconstructing knowledge brokering for commissioned rapid reviews: an observational study

Background

Knowledge brokers are increasingly used by policy agencies, yet little is known about how they engage with policy-makers and facilitate discussions with them about their research needs. This study examines knowledge brokers’ behaviour in one-off interactions with policy-makers commissioning rapid reviews. It describes how knowledge brokers engage with policy-makers, build trust and gain agreement about the review’s parameters.

Methods

We observed and transcribed 15 structured knowledge brokering sessions and used line-by-line analysis to derive, test and refine a coding schedule. The final coding schedule was applied to all transcripts. We assigned 35 codes to three tasks identified in the data, namely eliciting information, exploring the policy context and negotiating the content of reviews.

Results

The knowledge brokers we observed were skilled facilitators who built trust by their open stance, neutrality, and knowledge of research and policy contexts. Trust engendered an interplay of expertise in which review questions and scope were clarified and contextual factors evaluated. Negotiation about the content of the review focused on understanding how it would contribute to the policy process, comparing options and assessing feasibility. Key functions of knowledge brokers included eliciting and clarifying information, linking the review questions to the context and purpose, moving fluidly between policy and research perspectives, and weighing up review options against policy objectives. Four knowledge brokering roles were identified, namely diagnostic, facilitative, deliberative and interpretative.

Conclusions

This study identified ways in which knowledge brokers established rapport with policy-makers who commissioned reviews, enabled disclosure of essential information and explored contextual factors that affected the review’s purpose and intended use. Knowledge brokers were competent in the discourse and conventions of both policy and research and were skilled in negotiating complex policy and political environments, assisting policy-makers to evaluate options and craft a review proposal that was targeted, responsive and feasible. Mutuality, respect and an interplay of expertise were integral to the knowledge brokering process. Future research might usefully examine whether other rapid review programmes using knowledge brokers have similar results as well as the transferability of the four knowledge brokering roles to other contexts and settings.

Electronic supplementary material

The online version of this article (10.1186/s12961-018-0389-7) contains supplementary material, which is available to authorized users.

Free-operant forgetting: Delayed stimulus control of multiple-schedule performance

Pigeons' responses were reinforced in two components of several multiple variable-interval variable-interval schedules of food reinforcement. In one component, the key was illuminated green for 15 seconds and white for 45 seconds. In the other component, the key was illuminated red for 15 seconds and white for 45 seconds. Values for the exponent of the power functions relating response ratios to reinforcement ratios were higher in the presence of the discriminative stimuli (green or red) than in the presence of white. Sensitivity of response ratios to changes in reinforcement ratios provided an index of the extent to which responding was under delayed stimulus control by prior discriminative stimuli.

Predictors of smoking in pregnancy and attitudes and knowledge of risks of pregnant smokers

This study examined the prevalence and predictors of smoking by pregnant women attending a public antenatal clinic. The prevalence of smoking in this population (n = 2577) was found to be 38.0% (95% CI 36.1-39.9%). A review of previous research investigating variables associated with smoking in pregnancy indicated that only three of 42 studies had used multivariate analysis. Using step-wise logistic regression analysis, five variables were found to be independent predictors of smoking in pregnancy: education (having 4 years or less high school), marital status (being unmarried), gravidity (being multigravida), age (being under 25 years) and language spoken at home (speaking English). The model correctly predicted 63.7% of cases. The knowledge and attitudes of pregnant smokers were also investigated using data from a sub-sample of consenting subjects. Three-quarters of the women claimed that they had reduced their smoking since discovering they were pregnant. However, their mean intake of 13.7 cigarettes daily remained at a hazardous level. Approximately half (51%) these smokers claimed to have tried to quit smoking in the current pregnancy. Most (61%) women said they believed smoking was definitely harmful to the unborn child. However, awareness and acceptance of specific risks were inadequate. Of the women in a current relationship, 72% said their partner was a regular smoker. Less than half (45%) the continuing smokers who had seen a doctor about their current pregnancy could recall being advised to stop smoking. There is a need for health care providers to adopt a more systematic and tailored approach to smoking cessation counselling. Efforts to convert quit attempts in pregnancy into sustained cessation represent a priority area of programme development and evaluation.

Microdamage and altered vascularity at the enthesis–bone interface provides an anatomic explanation for bone involvement in the HLA–B27–associated spondylarthritides and allied disorders

OBJECTIVE

To describe the basis for entheseal-associated bone disease in the spondylarthritides, by analyzing microanatomic and histopathologic relationships between soft tissue, bone cortex, and adjacent trabeculae.

METHODS

Serial sections from 52 entheses were examined; these entheses encompassed small and large insertions in the upper limb (n = 21), lower limb (n = 27), and spine (n = 4) from 60 cadavers. Enthesis microdamage (fissuring) as well as vascular and reparative changes were evaluated. Contact radiographs were used to ascertain the relationship between entheses and the trabecular network.

RESULTS

At virtually all fibrocartilaginous entheses, the deep cortical boundary was extremely thin (typically 50-600 microm) or indistinguishable, and 96% of entheses had small holes in the cortical shell (typically 100-400 microm wide). Such regions were frequent sites of bone formation and renewal (96%) and microdamage (31%); these changes were more common in the lower limb. The presence of blood vessels near holes in the cortical shell was common; in 85% of attachments, blood vessels were present on the soft tissue side of the enthesis. Highly orientated trabeculae were more obvious in the lower limb than the upper limb (59% versus 29%).

CONCLUSION

The trabecular network supporting the cortical shell is an integral part of the enthesis, transferring load to an extensive skeletal region. In many cases, tendons/ligaments are anchored directly to such networks. This functional integration is associated with microdamage and repair at the hard tissue-soft tissue interface. These findings have implications for understanding bone involvement in SpA and for the SpA concept in general, especially the hypothesis that enthesis-bone architecture may be important in disease initiation.

Adipose tissue at entheses: the rheumatological implications of its distribution. A potential site of pain and stress dissipation?

OBJECTIVES

To describe the distribution of adipose tissue within and adjacent to entheses in order to assess its functional significance at attachment sites.

METHODS

Entheses were removed from 29 different sites in the limbs of formalin fixed, elderly, dissecting room cadavers and the samples prepared for paraffin and/or methylmethacrylate histology. Entheses from four young volunteers with no history of significant musculoskeletal injury were examined by magnetic resonance imaging using T(1) weighted sequences.

RESULTS

Adipose tissue was present at several different sites at numerous entheses. Many tendons/ligaments lay on a bed of well vascularised, highly innervated, "insertional angle fat". Endotenon fat was striking between fascicles, where entheses flared out at their attachments. It was also characteristic of the epitenon, where it occurred in conjunction with lamellated and Pacinian corpuscles. Fat filled, meniscoid folds often protruded into joint cavities, immediately adjacent to attachment sites.

CONCLUSION

Adipose tissue is a common feature of normal entheses and should not be regarded as a sign of degeneration. It contributes to the increase in surface area of attachment sites, promotes movement between tendon/ligament and bone, and forms part of an enthesis organ that dissipates stress. The presence of numerous nerve endings in fat at attachment sites suggests that it has a mechanosensory role and this could account for the rich innervation of many entheses. Because damage to fat is known to lead to considerable joint pain, our findings may be important for understanding the site of pain in enthesopathies.

A cost-effective approach to the development of printed materials: a randomized controlled trial of three strategies

Printed materials have been a primary mode of communication in public health education. Three major approaches to the development of these materials--the application of characteristics identified in the literature, behavioral strategies and marketing strategies--have major implications for both the effectiveness and cost of materials. However, little attention has been directed towards the cost-effectiveness of such approaches. In the present study, three pamphlets were developed using successive addition of each approach: first literature characteristics only ('C' pamphlet), then behavioral strategies ('C + B' pamphlet) and then marketing strategies ('C + B + M' pamphlet). Each pamphlet encouraged women to join a Pap Test Reminder Service (PTRS). Each pamphlet was mailed to a randomly selected sample of 2700 women aged 50-69 years. Registrations with the PTRS were monitored and 420 women in each pamphlet group were surveyed by telephone. It was reported that the 'C + B' and 'C + B + M' pamphlets were significantly more effective than the 'C' pamphlet. The 'C + B' pamphlet was the most cost-effective of the three pamphlets. There were no significant differences between any of the pamphlet groups on acceptability, knowledge or attitudes. It was suggested that the inclusion of behavioral strategies is likely to be a cost-effective approach to the development of printed health education materials.

The "enthesis organ" concept: why enthesopathies may not present as focal insertional disorders

OBJECTIVE

The Achilles tendon insertion is associated with a complex of adjacent fibrocartilages, a bursa, and a fat-pad, and is functionally much more than a focal insertion. This has important implications for a better understanding of the spondylarthropathies (SpA). However, the degree to which other insertions form comparable "enthesis organs" has not been established. The aim of this study was to demonstrate the applicability of the enthesis organ concept to other insertion sites.

METHODS

Both joint-related (articular) and extraarticular entheses were removed from 28 sites in the limbs of formalin-fixed cadavers (age at death 70-101 years) that had been donated for anatomic study. The samples were prepared for paraffin histologic analysis and sectioned longitudinally. The presence and extent of enthesis organs was evaluated at each site in serial sections stained with Masson's trichrome and toluidine blue.

RESULTS

Articular enthesis organs were found at 14 entheses, including the attachments of the digital extensor tendons and collateral ligaments, the cruciate ligaments, tibialis anterior, the lateral collateral ligament of the knee, and the popliteal tendon. Extraarticular enthesis organs were seen at 2 sites, the biceps brachii and patellar tendon insertions. In all enthesis organs, sesamoid and/or periosteal fibrocartilage was present in close association with synovium.

CONCLUSION

The concept of an enthesis organ is of general significance in understanding attachment sites and may explain the diverse pathologic changes, including synovitis, bursitis, and extracapsular changes, seen adjacent to tendon/ligament entheses in SpA. These findings may provide insight into the reason the target tissues in SpA are apparently so diverse.

Molecular composition and pathology of entheses on the medial and lateral epicondyles of the humerus: a structural basis for epicondylitis

OBJECTIVES

To improve the understanding of epicondylitis by describing the normal structure and composition of the entheses associated with the medial and lateral epicondyles and their histopathology in elderly cadavers.

METHODS

Medial and lateral epicondyles were obtained from 12 cadavers. Six middle aged cadavers (mean 47 years) were used to assess the molecular composition of "normal" entheses from people within an age range vulnerable to epicondylitis. Cryosections of epicondylar entheses were immunolabelled with monoclonal antibodies against molecules associated with fibrocartilage and related tissues. A further six elderly cadavers (mean 84 years) were used for histology to assess features of entheses related to increasing age.

RESULTS

Tendon entheses on both epicondyles fused with those of the collateral ligaments and formed a more extensive structure than hitherto appreciated. Fibrocartilage (which labelled for type II collagen and aggrecan) was a constant feature of all entheses. Entheses from elderly subjects showed extensive microscopic damage, hitherto regarded as a hallmark of epicondylitis.

CONCLUSIONS

Fibrocartilage is a normal feature and not always a sign of enthesopathy. Furthermore, pathological changes documented in patients with epicondylitis may also be seen in elderly people. The fusion of the common extensor and flexor tendon entheses with those of the collateral ligaments suggests that the latter may be implicated as well. This may explain why pain and tenderness in epicondylitis may extend locally beyond the tendon enthesis and why some patients are refractory to local treatments.

Print material content and design: is it relevant to effectiveness?

Printed materials are widely used in cancer education. There are a considerable number of guidelines in the literature on the content and design characteristics of print materials. However, there is little outcome-based evidence about whether materials containing these characteristics are more effective under real-world conditions. Six pamphlets were designed such that two had most of these characteristics, one had content characteristics only, one had design characteristics only and two had few of the characteristics. The pamphlets encouraged women aged 50-69 years to join a Pap Test Reminder Service (PTRS). The pamphlets were mailed to a randomly selected sample of 7668 women. Registrations with the PTRS were monitored. Receipt, readership, acceptability, knowledge and attitudes were assessed by telephone interview. There were no significant differences between the pamphlet groups in registrations with the PTRS, receipt, readership, acceptability, knowledge or attitudes. It was concluded that the inclusion of content and design characteristics does not result in more effective print materials.

Investigating breast symptoms in primary care: enhancing concordance with current best advice

The purpose of this study was to determine whether a targeted intervention could improve primary care practitioners' concordance with guidelines regarding management of women with breast symptoms. One hundred and twelve practitioners from randomly selected areas around Australia prospectively audited their investigations for each woman with a new breast symptom over two 12-week periods, before and five months after the release of national guidelines. Between the two audits, doctors received feedback on practice in relation to peers and attended one seminar in their local areas led by specialists from the Royal Australasian College of Physicians and the Royal Australasian College of Surgeons. For five recommendations, there were statistically significant improvements at the second audit in line with standard Investigation of a New Breast Symptom (INBS) guidelines. All these were for investigations of breast lumps. At first audit, there were seven recommendations where practitioners were already managing more than 80% of women in accordance with the INBS, and where there were no statistically significant increases in concordance at second audit. Another six recommendations had lower concordance with the recommendations prior to the release of the guidelines and did not significantly improve at second audit. These tended to be for less-common presentations and where clinical findings were not consistent with other test results. We concluded that a targeted intervention improved physician concordance with current best advice for investigating women who present with new breast symptoms in a primary care setting. Further educational programs are needed to improve investigations for rarer symptoms, and to enhance physicians' confidence in the results of their clinical examinations.

Prevalence of self-reported arm morbidity following treatment for breast cancer in the Australian Breast Cancer Family Study

Population-based women (n=1049) with breast cancer diagnosed mainly between 1996 and 1998, when aged 20-59 years, were mailed a questionnaire seeking information about self-reported shoulder stiffness and swelling, numbness and pain/ache in the arm following treatment (excluding 6 months from diagnosis). Of the 809 who completed the survey, approximately seven in eight experienced at least one symptom, one in six reported all four symptoms, and one in three considered that their arm morbidity interfered substantially with activities of daily living. Arm swelling occurred at some time in 39% of women, was present in 20% 1 year, and in 29% 4 years, after diagnosis. The prevalence of arm swelling was higher in women with axillary node dissection (OR=2.4; 95% Cl 1.0-5.6), and was increased in a women with a higher body mass index (P=0.02) and less education (P=0.01), but was not related to age, number of nodes excised or self-reports of radiation or type of surgery.

Differences in repair responses between immature and mature cartilage

Cartilage has a poor reparative capacity although it is unclear as to what extent this may be dependent on age or maturation. In the current study, the cellular responses of chondrocytes to experimental wounding in vitro using embryonic, immature, and mature cartilage have been compared. In all cases, the response was consistent (a combination of cell death that included apoptosis and proliferation). The speed of response varied in terms of cell death with embryonic cartilage showing the most rapid response and mature cartilage showing the slowest response. Intrinsic repair as assessed by the ability to heal the lesion was not detected in any of the culture systems used. It was concluded that the poor repair potential of cartilage is not maturation dependent in the systems studied.

Evaluating the effectiveness of advocacy training for breast cancer advocates in Australia

There is growing trend in health care for patients and consumers to have an active voice in all decisions related to their care. The purpose of the current study was to assess the effectiveness of an advocacy training programme for breast cancer consumers in Australia. The participants included 51 women who attended a 3-day advocacy training programme in three different states across Australia. Participants completed a pre- and post-questionnaire at 6 months follow-up to assess their involvement in breast cancer advocacy activities and organizations. Findings revealed a significant increase in participants' involvement in serving as a member of a board or committee, working on clinical trials recruitment issues, working on patient resources, and involvement in breast cancer advocacy groups after completing the training programme. However, no change was found in other key advocacy areas, such as, lobbying for change or reviewing research protocols. Implications for future advocacy training programmes and research were discussed.

The development and evaluation of an incontinence screening questionnaire for female primary care

Although there is a high prevalence of leaking urine among Australian women, there are currently no standardized procedures for screening patients for incontinence in the primary care setting (known in Australia as general practice). In response to this, an incontinence screening questionnaire (ISQ) was developed and evaluated for use in general practice. Eighty-nine women completed an original compilation of 33 items that asked about situations associated with leaking urine, avoidance of leakage, and concern about leakage. Each item was assessed according to its acceptability for the population of female general practice patients, discriminative value, and test-retest reliability. These patients also underwent an objective test of incontinence, the 48-hour pad test, so that the screening items could be validated against an objective classification of incontinence. The study included women who had bladder control problems and those who did not. Eight items on the ISQ were shown to be acceptable to patients, discriminative, reliable, and valid indicators of objective incontinence. Five items were capable of predicting almost 70% of patients who showed objective leakage of urine and misclassified fewer than 15% of these patients. Those five items were selected for inclusion in the (refined) ISQ.

Early discharge following breast surgery: assessing care, support, and informational needs of women with early breast cancer in Australia

BACKGROUND

The overall aims of the present study were to identify differences among women with early breast cancer who were discharged early from the hospital (within 48 h) and those who remained for routine admission in relation to demographic variables, informational needs, supportive needs, complications and satisfaction with care.

METHODS

A random sample of 544 women diagnosed with early breast cancer was recruited to participate in a telephone survey via State and Territory cancer registries.

RESULTS

Findings revealed little significant difference among women participating in early discharge and routine care in relation to demographics variables, informational needs, complication and satisfaction with care. Women participating in early discharge, however, were significantly less likely to be seen by a specialist breast care nurse or a volunteer with breast cancer.

CONCLUSIONS

Prior to establishing early discharge as routine care, it is essential to establish clear health policy relating to early discharge and adequate follow-up services for women with breast cancer.

Process measures in an antenatal smoking cessation trial: another part of the picture

Data on provider and patient compliance can be crucial in understanding the degree of a health education program's effectiveness, as well as in identifying areas where the program requires modification. However, such data are rarely systematically reported in randomized trials. This report assesses the degree to which doctors and midwives complied with intervention protocols in a hospital antenatal smoking cessation trial, and also examines the program's acceptability to patients. Provider compliance was assessed principally via consultation audiotapes and provider-completed checklists. The audiotape analysis identified substantial compliance problems. For example, in relation to six specific smoking-related pregnancy risks, the proportions of Experimental Women informed about each individual risk ranged from 26 to 38% and the proportions receiving counselling items ranged from 52 to 79%. Doctors only informed a minority of Experimental Women of the increased risk of Sudden Infant Death Syndrome (28%) and of the presence of toxic chemicals in tobacco (21%). Comparison of compliance data from audiotapes and provider checklists revealed there was no significant agreement in three of four cases tested. Experimental Patients completed questionnaires to assess recall of smoking advice and to rate 12 program features. Of specific Experimental Program elements, the videotape (85%) received the highest level of positive patient ratings and the lottery (42%) the lowest. The process evaluation indicated that the Experimental Program needed some modification to increase its suitability for routine application. The findings also support the value of including an objective measure of provider compliance.

Reliability and validity of women's recall of mammographic screening

OBJECTIVE

To assess the reliability and validity of self-reported attendance for mammographic screening.

METHODS

To assess reliability of recall of attendance for a screening mammogram, 100 women selected at random were interviewed twice (approximately one week apart). To assess validity, 127 women who reported having a mammogram within the national breast screening program (BreastScreen Australia) consented to having their reports verified by the national program.

RESULTS

Test-retest reliability for the question "Have you ever had a mammogram?" was perfect (agreement 100%, kappa 1). Validity was also high. About one-quarter of women (24.4%) recalled the exact date of their last mammogram and a further third (39.4%) correctly reported the month in which the mammogram was done. Almost all (91.3%) women reported the mammogram date accurately to within 12 months of the recorded date.

CONCLUSIONS

These data suggest that Australian women provide reliable and valid information in relation to mammographic screening attendance.

IMPLICATIONS

Self-reported data about attendance for mammographic screening are likely to provide reliable and valid estimates for research and health services evaluation purposes.

Knowledge and perceptions about breast cancer incidence, fatality and risk among Australian women

OBJECTIVE

Breast cancer is the most common fatal cancer among Australian women. This study aimed to provide an accurate national picture of women's understanding of breast cancer incidence, fatality and risk.

METHOD

A telephone survey explored the knowledge and perceptions of a sample of 2,935 Australian women in relation to breast cancer incidence, fatality, risk factors, risk perception and level of concern.

RESULTS

Australian women were well aware of breast cancer in general terms, however, there were major aspects of incidence and risk which were poorly understood. Only 5% of women nominated age as a risk factor, and only one-third were able to make an approximately correct estimate of the incidence of breast cancer in Australia.

CONCLUSIONS AND IMPLICATIONS

Recommendations for future information campaigns include targeting understanding of lifetime risk of developing breast cancer, age as a risk factor, survival from breast cancer and the need to separately address the perceptions of older versus younger women.

Perceptions of screening mammography among women aged 40-49

OBJECTIVE

The aim of this study was to survey women aged 40 to 49 to determine their perceptions of the benefits and the downsides of screening mammography for women in this age group, and the degree of support for targeting women aged 40 to 49 in the national BreastScreen program.

METHOD

Telephone interviews were used in a two-stage survey of 200 women aged 40 to 49 from across Australia in 1997. Information that outlined some of the evidence for costs and effectiveness of screening in this age group was sent to the women after the first survey.

RESULTS

Women saw both benefits and downsides of mammography screening in this age group. Although the proportion of women reporting downsides increased from (39%) to (69%), after reading the information most women (62%) still thought the benefits outweigh the downsides of offering a screening program to women aged 40-49 and the majority (66%) supported the notion of government funding for this. Most women agreed that women aged 40 to 49 have to be informed about all the advantages and disadvantages of screening before making a decision to attend.

CONCLUSION

If women aged 40-49 were to be actively recruited to a government screening program, an information campaign should be undertaken that outlines the benefits and downsides of screening mammography to foster informed participation.

IMPLICATIONS

Community views are a helpful contribution to debates about policy when existing data are ambiguous.

Surgeons' opinions about the NHMRC clinical practice guidelines for the management of early breast cancer

OBJECTIVE

To explore the opinions of surgeons about the NHMRC clinical practice guidelines for the management of early breast cancer (the Guidelines) and their views about and use of the accompanying Consumer's guide.

DESIGN

Cross-sectional telephone survey.

PARTICIPANTS AND SETTING

Surgeons throughout Australia who manage breast cancer, designated as "breast" or "general" (members or non-members of the Royal Australasian College of Surgeons' Section of Breast Surgery) and "urban" or "rural".

RESULTS

Among 150 respondents (64% response rate) more than 80% of surgeons reported having read all or most of the Guidelines and believed they were useful in improving women's management and wellbeing, easy to understand, evidence-based, a good summary of recent evidence, and that they would assist agreement between women and healthcare providers. Surgeons agreed with most of the recommendations in the Guidelines, but 26% disagreed that "women should ideally be treated by a specialist who treats a large number of similar patients and who has access to the full range of treatment options in a multidisciplinary setting". In terms of medicolegal implications, 41% believed that the Guidelines would protect clinicians, while, of the 37% of surgeons who believed that they would expose doctors to increased problems, significantly more breast than general surgeons believed this (50% v. 19%; P < 0.001). Only 37% of surgeons routinely gave the Consumer's guide to all or more than half their patients.

CONCLUSIONS

Surgeons are generally positive about the Guidelines, but certain issues should be addressed if they are to be optimally implemented, including confusion about the medicolegal implications, perceived difficulties with providing multidisciplinary care and poor use of the Consumer's guide.

Elderly patients with heart failure: a study of satisfaction with care and quality of life

OBJECTIVE

To assess the level of patient satisfaction with care, patient quality of life, the relationship between these measures and hospital readmission rates, and patient outcomes.

METHODOLOGY

A prospective cohort study was conducted of all patients aged 60 years and over admitted to the John Hunter and Mater Hospitals, in the Hunter Area, in whom congestive heart failure contributed to the need for hospital admission. Patients recruited into the main study were then asked to complete a questionnaire on discharge from hospital. Patients were asked to complete the satisfaction questionnaire on discharge because this would reflect the patients' satisfaction with the overall stay. To provide a baseline quality-of-life score, patients were asked to complete a questionnaire 2 weeks after discharge.

FINDINGS

Overall scores on the satisfaction questionnaire were high, indicating that the patients were very satisfied with their care. There were six questions in which 17-35% of patients indicated some degree of dissatisfaction, four related to patient knowledge. No difference in satisfaction was found between patients who had or did not have a readmission. Quality-of-life results showed that patients who had a readmission had a significantly lower quality-of-life score at 12 month follow up (P=0.007) than those without a readmission.

CONCLUSION

This finding has supported our hypothesis that a higher level of quality of life would be related to fewer readmissions.

Print material as a public health education tool

Despite the widespread use of print materials in public health education, little is known about the costs and processes involved in developing these materials and their effectiveness in practice. We examined a sample of printed health education materials, using interviews and checklists. The most cost-effective processes for developing materials were not being used and the effectiveness of materials was rarely evaluated.

Should women take part in clinical trials in breast cancer? Issues and some solutions

PURPOSE

The purpose of this review is to consider the issues for women related to participation in clinical trials that evaluate the management of breast cancer and provide some recommendations for future initiatives to address the identified areas of concern.

METHODS

The National Health and Medical Research Council (NHMRC) National Breast Cancer Centre hosted an international workshop to address the question "Clinical Trials in Breast Cancer: Should Women Take Part?" We also reviewed the literature on informed participation in clinical trials that was identified in a broadly based search that covered Medline, PsycLIT, and HealthPlan from 1986 to 1996.

RESULTS AND CONCLUSION

When women are asked to participate in a clinical trial, they are faced with a number of questions and dilemmas. These include issues related to the conduct and ethical considerations of the trial; the effect of participation or nonparticipation on treatment; the roles of the doctor as clinician and as researcher; the process of informed consent; the timing of the request for participation; and the benefits and costs of participation. A number of steps are identified that could help women decide whether to participate in clinical trials. These include provision of community information about clinical trials; establishment of independent brokers and registers for clinical trials; consumer review of information and protocols and involvement in trials; review of the role of ethics committees; collection of data about the proportion of women currently recruited to clinical trials, their reasons for participating or declining, and their views about the process of recruitment and participation; models for optimal practice in recruiting women to clinical trials and encouraging ongoing participation in trials; evidence-based communication skills training for clinicians to teach skills to inform women adequately of clinical trial participation; and auspicing and promotion of trials by an independent agency.

Mammographic screening: results from the 1996 National Breast Health Survey

OBJECTIVE

To establish the extent of women's knowledge of mammographic screening, particularly in relation to the national screening program, BreastScreen Australia, and to estimate the proportion of women who are participating in screening both within and outside BreastScreen Australia.

DESIGN AND SETTING

Validated prospective telephone survey of women aged 30-69 years selected at random from across Australia.

PARTICIPANTS

2935 women with no previous breast cancer diagnosis.

RESULTS

The adjusted response rate was 64%. Almost 90% of women had heard of the national program; only 1% correctly stated that screening is for asymptomatic women. 60% correctly identified the current recommended age of starting screening is about 50 years of age; 26% thought screening should begin at about 40 years of age. Approximately 60% correctly reported that the recommended screening interval is every two years; 27% thought screening should be done annually. 55% reported ever having had a mammogram, and 37% reported having had at least one screening mammogram. Among women in the target age group (50-69 years) about 70% reported ever having had a screening mammogram, and about 50% reported having had a screening mammogram within the national program in the last two years. Among women aged 40-49 years, 29% reported ever having had a screening mammogram, and 22% reported having been screened in the last two years.

CONCLUSIONS

Awareness of the national screening program is high, but some women do not know the purpose of screening, the target age group and the recommended screening interval. Compliance with screening is good among women in the target age group; many women in their 40s are also participating in screening.

Community action for health promotion: a review of methods and outcomes 1990-1995

OBJECTIVE

Our objective was to explore the effectiveness of community action as a strategy for health promotion, through a critical review of five years of community action evaluation literature.

METHODS

Community action was defined as a health promotion, program that involved the community in implementation and control of the process of the program. Criteria for scientific evaluation of programs were proposed for sampling and control procedures, reliability and validity of instruments, analysis techniques, and specification of details of the intervention. A critical review of the literature, located by an on-line and related reference search, was undertaken for community action aimed at reducing cancer and cardiovascular disease, between January 1990 and May 1995.

RESULTS

None of seven community action studies (17 articles) that examined cancer risk factors fulfilled all the criteria for rigorous scientific evaluation. The most methodologically adequate cancer study, the COMMIT intervention, had only a moderate degree of success in reducing community smoking rates. Similarly, none of the six studies (25 articles) on cardiovascular disease fulfilled all the criteria. The results for the most methodologically adequate study, the Minnesota Heart Health Program, were disappointing, with strong secular trends preventing adequate assessment of the intervention effect.

CONCLUSIONS

The finding that none of the reviewed studies met all evaluation criteria was due to several factors, including political considerations, feasibility, and the continued evolution of the science of evaluation in health promotion. Some important questions are posed for researchers by the failure of methodologically superior projects, such as COMMIT, to show major gains in reducing health risk behaviors.

A smoking cessation program at a public antenatal clinic

OBJECTIVES

A randomized trial evaluated the impact of smoking cessation interventions on point prevalence and consecutive quit rates at an Australian public prenatal clinic.

METHODS

Self-reports and urine cotinine tests confirmed patients' smoking status at the midpoint and end of pregnancy and 6 weeks postpartum.

RESULTS

At all points, validated abstinence rates were significantly higher in the experimental group than in the control group. The rate of failed biochemical validation was significantly higher in the control group than in the experimental group.

CONCLUSIONS

Prenatal clinic staff can significantly increase quit rates by using cognitive-behavioral strategies. Brief advice appears to be ineffective.

Consulting about priorities for the NHMRC National Breast Cancer Centre: how good is the nominal group technique

The National Health and Medical Research Council National Breast Cancer Centre was established to improve outcomes for women by reviewing the literature, developing best practice guidelines and resources and developing a national monitoring system. Its broad terms of reference meant that it was important at the outset to identify priorities for action. The Centre used a national consultative process based on nominal groups to identify priorities. Thirteen consultative workshops were held with over 300 participants including women diagnosed with breast cancer, some of their families and health professionals. There was a high level of agreement between workshops in priorities identified, indicating that the nominal group process results in reliable data. A sub-sample of participants surveyed after the workshops reported being highly satisfied with their participation in the process. The findings indicate that the nominal group process can be useful in selecting priorities for action in health.

Environmental hazards in the homes of older people

OBJECTIVES

To investigate (i) the prevalence of environmental safety hazards in the homes of people aged 70 years and over, (ii) their knowledge of causes of injuries to older people and the safety measures they can implement to prevent such injuries and (iii) the relationship between socio-demographic characteristics of this population group and levels of home environmental hazards.

METHOD

A cross-sectional survey of 425 people aged 70 years and older living in a defined geographical area of Australia. Participants were recruited through their general practitioners. A structured interview completed with each participant included questions on demographics and home safety issues. A home safety inspection was also undertaken using a predetermined rating format.

RESULTS

80% (n = 342) of homes inspected had at least one hazard and 39% (n = 164) had > 5 hazards. The bathroom was identified as the most hazardous room, with 66% (n = 279) of bathrooms having at least one hazard. Hazards relating to floor surfaces (62% of homes had one 'flooring' hazard) and absence of appropriate grab or handrails (60% of homes had one or more hazards relating to this) were prevalent. Eighty-eight percent (n = 374) of older people were able to identify falls as the most common cause of injury and 87% (n = 368) were able to accurately name at least one safety measure. Although a significant association was found between the older people's self-assessment of their home's safety and the presence of more than 5 hazards, 30% of those rating their homes as very safe (n = 289) had more than 5 hazards. Logistic regression analysis identified one variable--contact with healthcare service providers--as predictive of the hazard level in older people's homes. Older people who were never visited by service providers were twice as likely to have more than 5 hazards as those who were visited weekly or more often (OR 2.12, 95% CI 1.104, 4.088).

CONCLUSION

Many older people are living in potentially hazardous environments. As yet, a causal link between the presence of environmental hazards and falls in older people has not been established. More definitive work in this area needs to be carried out.

The accuracy of self-reported Pap smear utilisation

This study assessed the accuracy of self-reported Pap smear utilisation over four different time frames, examining the magnitude of errors in self-report and sociodemographic predictors of accuracy. Self-report data on women's cervical screening was collected by interview in a random household survey (Hunter Region, NSW, Australia), with pathology laboratory data collected by a search of records within laboratories. The magnitude of error in self-report was assessed by comparing it against longer intervals in pathology laboratory data. Sociodemographic predictors of accuracy were explored using chi square analyses. Low values for specificity and positive predictive value across all four time frames indicate a considerable degree of inaccuracy in women's reporting of those instances where, in truth, screening has not occurred. Of women reporting a smear within the last three years, only 61.2% were verified within pathology laboratory records. Allowing women some "leeway" in their reporting, comparing self-report to longer intervals of pathology laboratory data, did not greatly improve the accuracy of reporting, confirming that the magnitude of inaccuracy involved is of real clinical significance. Demographic variables were not related to the accuracy of self-report and, while a woman's certainty of her response was predictive, this had little impact on the measures of agreement. Self-report of Pap smear histories consistently results in over-reporting of screening. Other means of assessing the prevalence of screening may be preferable to self-report. Where self-report data is collected, techniques to improve accuracy should be employed, and care should be taken in comparing screening rates obtained by different methods.

Disordered eating and unhealthy weight reduction practices among adolescent females

BACKGROUND

Dissatisfaction with body weight and the use of unhealthy weight reduction practices have been reported among adolescent females. There is a need for methodologically rigorous studies using large representative samples of adolescent females to accurately assess the prevalence of these behaviors and attitudes.

METHODS

Eight hundred sixty-nine Australian school girls ages 14-16 years were administered a self-report questionnaire to determine the prevalence of disordered eating behaviors, unhealthy dieting practices, and distorted body image. Anthropometric (height and weight) data were collected on each of these adolescent females.

RESULTS

The prevalences of disordered eating, unhealthy dieting, and distorted body image were 33, 57, and 12%, respectively. Over one-third (36%) of the total sample had used at least one "extreme" dieting method in the past month, i.e., "crash" dieting, fasting, slimming tablets, diuretics, laxatives, and/or cigarettes to lose weight. Of the total sample, 77% wanted to lose weight and 51% had tried to lose weight in the past month. Motivating factors for disordered eating and unhealthy dieting behaviors were peer pressure, media pressure, and the perception that extreme dieting strategies were harmless.

CONCLUSION

The prevalence of disordered eating and dieting behaviors among adolescent females shown by this study suggests the need for preventive programs encouraging appropriate eating and dieting behaviors.

Knowledge of cancer risk reduction practices in rural towns of New South Wales

The Australian Cancer Society has published guidelines for recommended risk reduction strategies for breast, cervical, smoking-related and skin cancer. While knowledge may not be sufficient for change, it is argued to be necessary for change to occur. A measure of the level of health knowledge in the community can be useful for health promotion practitioners, identifying where health messages are not reaching their proposed targets. Our aims were to examine the level of knowledge about risk reduction practices for breast, cervical, smoking-related and skin cancers, for a rural New South Wales sample, and to examine sex and age effects on knowledge levels. A survey of 2846 women and 1732 men from rural New South Wales, which used an unprompted recall strategy, revealed some notable deficits in recall of cancer risk reduction practices: only 26 per cent of women identified mammograms as a risk reduction strategy for breast cancer; only 5 per cent of women knew at which ages mammograms should start and stop; only 6 per cent of women could identify when Pap tests should be discontinued; less than half of the sample could identify common solar protection strategies; and less than one-third of people identified passive smoking as a lung cancer risk.

The hippocampus, long-term potentiation and memory

1. The induction of long-term potentiation (LTP) at excitatory synapses on CA1 pyramidal neurons occurs partly through an increase in the quantal AMPA current. It is also accompanied by an increase in the number of active sites. Any presynaptic modification, requiring the presence of a retrograde messenger, remains uncertain. 2. There are no definitive data that establish a causal link between LTP and the formation of memories. Pharmacological blockage of NMDA and mGLU receptors and genetic mutants with proteins deleted that are thought to be involved in LTP induction or maintenance or in the formation of memories have all linked deficits in LTP with impairments to behavioural learning, but these links are not necessarily causal. The development of tissue- and time-specific lesion of gene expression for multiple gene products may overcome the present limitations of gene deletion experiments and provide more revealing insights into the relationship between LTP and memory.

The accuracy of self-report of smoking status in pregnant women

Little is known about the accuracy of usual-care providers' detection of pregnant smokers. This study explored the proportion of pregnant women misclassified as nonsmokers by midwives in a public antenatal clinic. A sample of 204 women whom midwives classified as nonsmokers were asked to complete a self-administered questionnaire and to provide a urine specimen for cotinine analysis. Results indicate that midwives failed to detect a significant proportion of smokers. The conservative estimate of the proportion of midwife-identified nonsmokers who could be reclassified as smokers on the basis of the questionnaire and urinalysis procedures was 7.4% (95% CI 3.8-10.9%), the medium estimate was 8.8% (95% CI 4.9-12.7%) and the worst-case estimate was 15.2% (95% CI 10.3-20.1%). To increase the coverage achieved by smoking-cessation programs, antenatal clinics should consider incorporating biochemical measurements into routine screening procedures. Future studies examining smoking status in pregnancy should detail the methods used to classify subjects and document response rates in relation to each self-report and biochemical measurement.