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Purpose: Adults who stutter (AWS) have increased risk of comorbid social anxiety about speaking in social contexts. AWS also report experiencing embarrassment in different social situations; however, research has rarely been conducted on embarrassment and its relationship to social anxiety in AWS. Method: AWS (N = 200) reported their level of embarrassment on four 10-point Likert items when speaking in four situational contexts: at home, to an individual important to them, in social groups, and at work. Participants were also assessed for sociodemographic, stuttering, and anxiety variables. Construct validity for the four embarrassment items was examined, the extent of embarrassment established in the four contexts as a function of age and sex, and the relationship of embarrassment to social anxiety evaluated. Results: Evidence of acceptable construct validity and reliability is presented for the four embarrassment Likert items. Sixty-five percent of the sample experienced high levels of embarrassment when speaking in groups or at work, while 35.5% experienced high levels when speaking at home or to an individual important to them. Participants were significantly more embarrassed (p < 0.01) when speaking at work or when socializing in groups. Embarrassment was lowest when speaking in the home. Younger females were significantly more embarrassed when speaking at work or when socializing in groups. Those with high embarrassment scores on all four items were more likely to have elevated social anxiety scores (p < 0.001). Conclusion: These preliminary results suggest that the assessment of situational embarrassment could be an important clinical measure that may help improve stuttering treatment outcomes that also target social anxiety.

Adherence to cancer treatment clinical practice guidelines (CPGs) varies enormously across Australia, despite being associated with improved patient outcomes. This systematic review aims to characterize adherence rates to active‐cancer treatment CPGs in Australia and related factors to inform future implementation strategies. Five databases were systematically searched, abstracts were screened for eligibility, a full‐text review and critical appraisal of eligible studies performed, and data extracted. A narrative synthesis of factors associated with adherence was conducted, and the median adherence rates within cancer streams calculated. A total of 21,031 abstracts were identified. After duplicates were removed, abstracts screened, and full texts reviewed, 20 studies focused on adherence to active‐cancer treatment CPGs were included. Overall adherence rates ranged from 29% to 100%. Receipt of guideline recommended treatments was higher for patients who were younger (diffuse large B‐cell lymphoma [DLBCL], colorectal, lung, and breast cancer); female (breast and lung cancer), and male (DLBCL and colorectal cancer); never smokers (DLBCL and lung cancer); non‐Indigenous Australians (cervical and lung cancer); with less advanced stage disease (colorectal, lung, and cervical cancer), without comorbidities (DLBCL, colorectal, and lung cancer); with good‐excellent Eastern Cooperative Oncology Group performance status (lung cancer); living in moderately accessible places (colon cancer); and; treated in metropolitan facilities (DLBLC, breast and colon cancer). This review characterized active‐cancer treatment CPG adherence rates and associated factors in Australia. Future targeted CPG implementation strategies should account for these factors, to redress unwarranted variation particularly in vulnerable populations, and improve patient outcomes (Prospero number: CRD42020222962). [ABSTRACT FROM AUTHOR]

Background: Often considered an "invisible disability", hearing loss is one of the most prevalent chronic diseases and the third leading cause for years lived with disability worldwide. Hearing loss has substantial impacts on communication, psychological wellbeing, social connectedness, cognition, quality of life, and economic independence. The Hearing impairment in Adults: a Longitudinal Outcomes Study (HALOS) aims to evaluate the: (1) impacts of hearing devices (hearing aids and/or cochlear implants), (2) differences in timing of these interventions and in long-term outcomes between hearing aid and cochlear implant users, and (3) cost-effectiveness of early intervention for adult-onset hearing loss among hearing device users. Materials and methods: HALOS is a mixed-methods study collecting cross-sectional and longitudinal data on health and social outcomes from 908 hearing aid and/or cochlear implant users aged ≥40 years, recruited from hearing service providers across Australia. The quantitative component will involve an online survey at baseline (time of recruitment), 24-months, and 48-months and will collect audiological, health, psychosocial, functional and employment outcomes using validated instruments. The qualitative component will be conducted in a subset of participants at baseline and involve semi-structured interviews to understand the patient journey and perspectives on the Australian hearing service model. Ethics: This study has been approved by the Macquarie University Human Research Ethics Committee (ID: 11262) and Southern Adelaide Local Health Network (ID: LNR/22/SAC/88). Dissemination of results: Study findings will be disseminated to participants via a one-page summary, and to the public through publications in peer-reviewed journals and presentations at conferences. Trial registration: Australia New Zealand Clinical Trial Registry (ANZCTR) registration number: ACTRN12622000752763. [ABSTRACT FROM AUTHOR]

Background: People with early-onset colorectal cancer, under the age of 50, are more likely to experience diagnostic delay and to be diagnosed at later stages of the disease than older people. Advanced stage diagnosis potentially requires invasive therapeutic management at a time of life when these patients are establishing intimate relationships, raising families, building careers and laying foundations for financial stability. Barriers to timely diagnosis at primary care level have been identified but the patient perspective has not been investigated. Methods: Personal accounts of cancer care are increasingly accessed as rich sources of patient experience data. This study uses mixed methods, incorporating quantitative content analysis and qualitative thematic analysis, to investigate patients' accounts of early-onset colorectal cancer diagnosis published on prominent bowel cancer support websites in the United Kingdom, Australia and New Zealand. Results: Patients' perceptions (n = 273) of diagnostic barriers at primary care level were thematically similar across the three countries. Patients perceived that GPs' low suspicion of cancer due to age under 50 contributed to delays. Patients reported that their GPs seemed unaware of early-onset colorectal cancer and that they were not offered screening for colorectal cancer even when 'red flag' symptoms were present. Patients described experiences of inadequate information continuity within GP practices and across primary, specialist and tertiary levels of care, which they perceived contributed to diagnostic delay. Patients also reported tensions with GPs over the patient-centredness of care, describing discord related to symptom seriousness and lack of shared decision-making. Conclusions: Wider dissemination of information about early-onset colorectal cancer at primary care level is imperative given the increasing incidence of the disease, the frequency of diagnostic delay, the rates of late-stage diagnosis and the dissatisfaction with patient experience reported by patients whose diagnosis is delayed. Patient education about diagnostic protocols may help to pre-empt or resolve tensions between GPs' enactment of value-based care and patients' concerns about cancer. The challenges of diagnosing early-onset colorectal cancer are significant and will become more pressing for GPs, who will usually be the first point of access to a health system for this growing patient population. [ABSTRACT FROM AUTHOR]

Purpose: Dietary flavonoids are bioactive compounds that have been widely investigated for their associations with vascular health outcomes. As the development of tinnitus has been linked to vascular pathways, dietary flavonoids may have role in the prevention of tinnitus symptoms. This study reports the associations between the intakes of major classes of dietary flavonoids and 10-year incidence of tinnitus. Methods: Of the 1753 participants (aged ≥ 50 years) from the Blue Mountains Hearing Study with complete baseline data on tinnitus symptoms and dietary intakes, 536 (31%) cases of tinnitus were identified and excluded from further analysis. Dietary data was collected using a semi-quantitative food frequency questionnaire and intakes of the five major classes of flavonoids were determined using U.S. Department of Agriculture flavonoid databases. Presence of prolonged tinnitus was assessed by a positive response to a single question administered by an audiologist. Results: Of the remaining 1217 participants without tinnitus at baseline, 222 (18%) incident cases of tinnitus were identified over 10 years. After age–sex adjustment, participants in the third versus first quartile of proanthocyanidin intake were significantly less likely to develop incident tinnitus by 36% (HR = 0.64; 95% CI 0.43–0.96, Ptrend = 0.04). Following multivariable adjustment, this protective trend was non-significant (HR = 0.60; 95% CI 0.39–0.92; Ptrend = 0.06). Similarly, a non-significant protective trend was observed when comparing the fourth versus first quartile of intake of all flavonoids (OR = 0.61; 95% CI 0.39–0.96). No other associations were observed. Conclusion: Our findings do not support the hypothesis that dietary flavonoids are protective against the development of tinnitus over 10 years. The weak significant association observed between proanthocyanidin and incident tinnitus may be a chance finding as there was no significant trend following multivariate adjustments and, therefore, requires further studies to investigate these associations. [ABSTRACT FROM AUTHOR]

Background: Hospitals are perceived as fast-paced and complex environments in which a missed or incorrect diagnosis or misread chart has the potential to lead to patient harm. However, to date, limited attention has been paid to studying how hospital sociotemporal norms may be associated with staff wellbeing or patient safety. The aim of this study was to use novel network analysis, in conjunction with well-established statistical methods, to investigate and untangle the complex interplay of relationships between hospital staff perceived sociotemporal structures, staff safety attitudes and work-related well-being.Method: Cross-sectional survey data of hospital staff (n = 314) was collected from four major hospitals in Australia. The survey included subscales from the Organizational Temporality Scale (OTS), two previously established scales of safety attitudes (teamwork climate and safety climate) and measures of staff-related wellbeing (job satisfaction, emotional exhaustion, depersonalisation).Results: Using confirmatory factor analysis, we first tested a 19-item version of the OTS for use in future studies of hospital temporality (the OTS-H). Novel psychological network analysis techniques were then employed, which identified that "pace" (the tempo or rate of hospital activity) occupies the central position in understanding the complex relationship between temporality, safety attitudes and staff wellbeing. Using a path analysis approach, serial mediation further identified that pace has an indirect relationship with safety attitudes through wellbeing factors, that is, pace impacts on staff wellbeing, which in turn affects hospital safety attitudes.Conclusions: The findings of this study are important in revealing that staff wellbeing and safety attitudes can be significantly improved by placing more focus on temporal norms, and in particular hospital pace. There are implications for increasing levels of trust and providing staff with opportunities to exercise greater levels of control over their work. [ABSTRACT FROM AUTHOR]

Background: The views and experiences of the Australian public are an important barometer of the health system. This study provides key findings about the changing views held by Australians over time regarding their individual experiences and perceptions of the overall performance of the health system. Methods: A population‐based online survey was conducted in 2018 (N = 1024). Participants were recruited through market research panels. The results were compared with previous Australian population survey data sets from 2008 (N = 1146), 2010 (N = 1201) and 2012 (N = 1200), each of which used different population samples. The survey included questions consistent with previous surveys regarding self‐reported health status, and questions about use, opinions and experiences of the health system. Results: Overall, there has been a shift in views from 2008 to 2018, with a higher proportion of respondents now viewing the Australian health‐care system more positively (X2 (2, N = 4543) = 96.59, P <.001). In 2018, areas for attention continued to include the following: the need for more doctors, nurses and other health workers (29.0%); lower costs for care or Orion medicines (27.8%); more access to care (13.1%); and enhancements in residential aged care (17.3% rated these services as 'bad' or 'very bad'). Conclusions: This research suggests that Australians' perceptions of their health‐care system have significantly improved over the last decade; however, concerns have emerged over access to medicines, inadequate workforce capacity and the quality of aged care facilities. Our study highlights the value of periodically conducting public sentiment surveys to identify potential emerging health system problems. [ABSTRACT FROM AUTHOR]

Background: Broken windows theory (BWT) proposes that visible signs of crime, disorder and anti-social behaviour - however minor - lead to further levels of crime, disorder and anti-social behaviour. While we acknowledge divisive and controversial policy developments that were based on BWT, theories of neighbourhood disorder have recently been proposed to have utility in healthcare, emphasising the potential negative effects of disorder on staff and patients, as well as the potential role of collective efficacy in mediating its effects. The aim of this study was to empirically examine the relationship between disorder, collective efficacy and outcome measures in hospital settings. We additionally sought to develop and validate a survey instrument for assessing BWT in hospital settings.Methods: Cross-sectional survey of clinical and non-clinical staff from four major hospitals in Australia. The survey included the Disorder and Collective Efficacy Survey (DaCEs) (developed for the present study) and outcome measures: job satisfaction, burnout, and patient safety. Construct validity was evaluated by confirmatory factor analysis (CFA) and reliability was assessed by internal consistency. Structural equation modelling (SEM) was used to test a hypothesised model between disorder and patient safety and staff outcomes.Results: The present study found that both social and physical disorder were positively related to burnout, and negatively related to job satisfaction and patient safety. Further, we found support for the hypothesis that the relationship from social disorder to outcomes (burnout, job satisfaction, patient safety) was mediated by collective efficacy (social cohesion, willingness to intervene).Conclusions: As one of the first studies to empirically test theories of neighbourhood disorder in healthcare, we found that a positive, orderly, productive culture is likely to lead to wellbeing for staff and the delivery of safer care for patients. [ABSTRACT FROM AUTHOR]

Objective: This study outlines development of an instrument for measuring attitudes of medical students towards older people, the Australian Ageing Semantic Differential (AASD). Methods: Words for AASD scales were derived from the reflections of 151 third year medical students attending two Australian medical schools. A pilot study of the AASD was then undertaken with third year students at another medical school to confirm usability and reliability of the instrument. After slight modification, a larger study using the AASD was then undertaken of medical students attending the three institutions, in order to obtain sufficient data for exploratory factor analysis. Results: n = 321 (response rate 73%). Mean AASD score 73.2/114. Cronbach's α = 0.86. There was no evidence of sequence bias. Exploratory factor analysis (EFA) demonstrated four factors: Instrumentality; Personal Appeal; Experience; and Sociability. A lower mean instrumentality subscore for all students and a higher mean experience subscore for female students were noted. Conclusions: The AASD instrument proved internally reliable, and its use was generalisable to different groups of medical students. Its design ensured construct and face validity, and responses were not affected by sequencing bias. This study has revealed positive student attitudes towards older people. Variation in attitudes requires further investigation. [ABSTRACT FROM AUTHOR]

Major goals of rehabilitation and health interventions in people with spinal cord injury (SCI) are to improve functional independence, increase social participation, and enhance quality of life (QOL). Determining functional areas perceived by consumers as most important can assist in research prioritization, planning for delivery of health services, and policy development. Five high priority areas of functioning for the SCI population (arm/hand use, walking, bladder/bowel control, sexual function, and relief of pain) were chosen to determine the preferences for these five attributes. A discrete choice experiment was conducted involving 151 persons with SCI sampled from Australia and the United States of America. Consistent with prior research, arm/hand function had the highest preference, with odds ratios of subjects being 44-76% more likely to choose arm/hand function over the other four functions. Preference for normal arm/hand function was found to be significantly more preferred by the group with paraplegia compared with those with tetraplegia; that is, retaining and not trading off existing arm/hand function for other improved functions. There were no significant differences found in preferences between bladder/bowel function and walking or elimination of pain, although walking was preferred in earlier (≤10) post-injury years and pain amelioration became more important with a longer duration (>10 years) post-injury. Sexual function had the lowest preference when traded against the other four functions. Understanding the functional preferences of persons with SCI will help to inform future research design, as well as enabling successful translation of research into practice and health policy, meeting the needs of people with SCI. [ABSTRACT FROM AUTHOR]

Background: Motor vehicle related moderate-severe orthopaedic trauma has a major impact on the burden of injury. In Australia, all states and territories provide access to financial compensation following injury in a motor vehicle crash. The aim of this study was to investigate the influence of seeking financial compensation (i.e., making a claim) on injury recovery following motor vehicle related moderate-severe orthopaedic trauma.Methods: Patients admitted with upper/lower extremity fractures after a motor vehicle crash were recruited from two trauma hospitals. Baseline data were collected in person by written questionnaire within two weeks of injury. Follow up data were collected by a mailed written questionnaire at six, 12 and 24 months. Additional (demographic/injury-related) information was collected from hospital databases, all other measures were self-reported. Outcomes were: Short Form-36 Version 2.0 (SF36v2), Physical/Mental Component Scores (PCS/MCS); Post Traumatic Stress Disorder (PTSD) Checklist Civilian Version (PCL-C); and Global Rating of Change (GRC) scale. Analysis involved descriptive statistics and linear mixed models to examine the effect of compensation status on injury recovery over time.Results: There were 452 study participants. Baseline characteristics showed: mean age 40 years (17.1 Standard Deviation [SD]); 75 % male; 74 % worked pre-injury; 67 % in excellent-very good pre-injury health; 56 % sustained serious injuries, Injury Severity Score (ISS) 9-15; 61 % had a low-middle range household income. Overall, after controlling for possible confounders, the compensable group had poorer recovery compared to the non-compensable group for PCS (-2.97 Mean Difference (MD), 95 % CI -4.73, -1.22); MCS (-3.44 MD, 95 % CI -5.62, -1.26); PCL-C (3.42MD, 95 % CI 0.87, 5.99); and GRC (-0.66MD, 95 % CI -1.15, -0.17). Injury recovery over time for all participants showed: PCS improved from 6-12 and 12-24 months; MCS and GRC improved from 6-12 months; and PCL-C did not significantly improve from 6-12 and 12-24 months. Injury recovery over time continued for compensable and non-compensable groups but compensable participants had poorer scores at each time period, especially MCS and PCL-C.Conclusions: Making a claim was associated with poor injury recovery following motor vehicle related orthopaedic trauma, mainly for mental health. Irrespective of claim status, the majority had poor injury recovery, especially for mental health. [ABSTRACT FROM AUTHOR]

Adherence to cancer treatment clinical practice guidelines (CPGs) varies enormously across Australia, despite being associated with improved patient outcomes. This systematic review aims to characterize adherence rates to active-cancer treatment CPGs in Australia and related factors to inform future implementation strategies. Five databases were systematically searched, abstracts were screened for eligibility, a full-text review and critical appraisal of eligible studies performed, and data extracted. A narrative synthesis of factors associated with adherence was conducted, and the median adherence rates within cancer streams calculated. A total of 21,031 abstracts were identified. After duplicates were removed, abstracts screened, and full texts reviewed, 20 studies focused on adherence to active-cancer treatment CPGs were included. Overall adherence rates ranged from 29% to 100%. Receipt of guideline recommended treatments was higher for patients who were younger (diffuse large B-cell lymphoma [DLBCL], colorectal, lung, and breast cancer); female (breast and lung cancer), and male (DLBCL and colorectal cancer); never smokers (DLBCL and lung cancer); non-Indigenous Australians (cervical and lung cancer); with less advanced stage disease (colorectal, lung, and cervical cancer), without comorbidities (DLBCL, colorectal, and lung cancer); with good-excellent Eastern Cooperative Oncology Group performance status (lung cancer); living in moderately accessible places (colon cancer); and; treated in metropolitan facilities (DLBLC, breast and colon cancer). This review characterized active-cancer treatment CPG adherence rates and associated factors in Australia. Future targeted CPG implementation strategies should account for these factors, to redress unwarranted variation particularly in vulnerable populations, and improve patient outcomes (Prospero number: CRD42020222962)., (© 2023 The Authors. Asia-Pacific Journal of Clinical Oncology published by John Wiley & Sons Australia, Ltd.)

Objective: People with early-onset colorectal cancer (EOCRC), defined as colorectal cancer (CRC) before the age of 50, now constitute a significant patient population. In empirical and grey literature EOCRC patients report unsatisfactory experiences of care, especially in relation to protracted intervals from first help-seeking to diagnosis. This study is the first to investigate EOCRC patients' perspectives on ways to improve experiences of care. The objective is to provide foundational knowledge for the development of EOCRC-specific patient-reported experience measures (PREMs)., Design: The study was designed as qualitative Internet Mediated Research, involving a thematic analysis of unsolicited narratives recounting personal experiences of EOCRC care. We examined advice-giving statements in 120 online texts written by EOCRC patients and survivors., Setting: The Internet is the broad research setting. The host websites of three prominent charitable CRC support organisations were selected as specific research sites: Bowel Cancer Australia, Bowel Cancer UK and Bowel Cancer New Zealand., Results: We found that 90% of texts comprised statements of advice to new patients about the importance of self-advocacy in achieving quality care. Four key contexts for self-advocacy were identified: (1) accessing relevant diagnostic services; (2) driving diagnostic investigations when symptoms are not resolved; (3) involvement in treatment decision-making and (4) proactivity about preferred outcomes. Over 30% of advice-giving texts also directed statements of advice to healthcare providers, indicating that their youthfulness had been a barrier to timely diagnosis., Conclusion: Healthcare barriers to, and facilitators of, patient self-advocacy may be indicators of quality EORC care. There is a need for greater awareness of the impact of age bias on the responsiveness of clinicians and healthcare services in EOCRC care. Our findings support the development of EOCRC-specific PREMs that can guide age-appropriate policy and practice for this newly identified patient population., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Study Design: Cross-sectional survey., Objectives: To identify common problems across key domains of functioning, health and wellbeing, as well as evaluate self-reported quality of life (QoL) by people with SCI, examining differences by age, gender, injury characteristics and level of mobility., Setting: Data from four state-wide SCI clinical services, one government insurance agency and three not-for-profit consumer organisations., Methods: Participants were 18 years or over with SCI and at least 12 months post-injury, recruited between Mar'18 and Jan'19. The Aus-InSCI questionnaire comprised 193 questions, including socio-demographics, SCI characteristics, body functions and structures, activities and participation, environmental and personal factors, and appraisal of health and well-being. General linear model was used to examine differences in functioning and QoL., Results: Participants (mean age 57 years, range 19-94 years) with tetraplegia and/or complete injuries had more health problems, activity/participation problems and environmental barriers. However, self-rated overall QoL did not differ for injury level or completeness. Participants with more recent injuries exhibited lower independence levels, more mental health problems and poorer satisfaction with self and their living conditions. Major activity/participation problems related to intimate relationships and accessing public transportation. Less than half of the working age population were engaged in paid work. The top two environmental barriers frequently related to accessing public places or homes and unfavourable climatic conditions., Conclusions: This large, comprehensive community survey draws a detailed picture of the lived experience of people with SCI in Australia, identifying priority needs, gaps in services and barriers to achieving a full and satisfying life., (© 2022. Crown.)

Tinnitus is the phantom perception of sound in the ears or head that increases in prevalence as age increases. With strong evidence supporting the benefits of dietary fibre for vascular health and hearing loss, intake of dietary fibre may also have a role in the prevention of tinnitus symptoms. This longitudinal study aims to determine the association between the intake of dietary fibre and other carbohydrate nutrition variables including glycaemic index (GI), glycaemic load (GL) and total carbohydrate intakes, and incident tinnitus over 10 years. Of the 1730 participants (aged ≥50 years) from the Blue Mountains Hearing Study with complete baseline data on tinnitus symptoms and carbohydrate intakes, 536 (31%) cases of tinnitus were identified and excluded from further incidence analysis. Dietary data were collected using a validated semi-quantitative food frequency questionnaire to determine intakes of total dietary fibre and fibre contributions from cereals, vegetables, and fruit. A purpose-built database based on Australian GI values was used to calculate mean GI. Lower versus higher intakes of fruit fibre (≤3.6 g/day vs. >3.6 g/day) and cereal fibre (≤4.2 g/day vs. >4.2 g/day) were significantly associated with a 65% (HR = 1.65; 95% CI: 1.15-2.36) and 54% (HR = 1.54; 95% CI: 1.07-2.22) increased risk of developing tinnitus over 10 years, respectively. Associations between intake of other carbohydrate nutrients and incident tinnitus were mostly non-significant. In summary, our study showed modest associations between intake of dietary fibre and incident tinnitus. The protective effects of fibre, particularly insoluble fibre, could underlie observed associations by reducing the risk of tinnitus via vascular risk factors such as cardiovascular disease. Further longitudinal studies evaluating different types and sources of fibre and tinnitus risk are needed to confirm our study findings.

Introduction: Clinical practice guidelines (CPGs) synthesise the latest evidence to support clinical and patient decision-making. CPG adherent care is associated with improved patient survival outcomes; however, adherence rates are low across some cancer streams in Australia. Greater understanding of specific barriers to cancer treatment CPG adherence is warranted to inform future implementation strategies.This paper presents the protocol for a systematic review that aims to determine cancer treatment CPG adherence rates in Australia across a variety of common cancers, and to identify any factors associated with adherence to those CPGs, as well as any associations between CPG adherence and patient outcomes., Methods and Analysis: Five databases will be searched, Ovid Medline, PsychInfo, Embase, Scopus and Web of Science, for eligible studies evaluating adherence rates to cancer treatment CPGs in Australia. A team of reviewers will screen the abstracts in pairs according to predetermined inclusion criteria and then review the full text of eligible studies. All included studies will be assessed for quality and risk of bias. Data will be extracted using a predefined data extraction template. The frequency or rate of adherence to CPGs, factors associated with adherence to those CPGs and any reported patient outcome rates (eg, relative risk ratios or 5-year survival rates) associated with adherence to CPGs will be described. If applicable, a pooled estimate of the rate of adherence will be calculated by conducting a random-effects meta-analysis. The systematic review will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines., Ethics and Dissemination: Ethics approval will not be required, as this review will present anonymised data from other published studies. Results from this study will form part of a doctoral dissertation (MB), will be published in a journal, presented at conferences, and other academic presentations., Prospero Registration Number: CRD42020222962., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Spinal cord injury (SCI) is associated with autonomic imbalance and significant secondary conditions, including cardiac and brain dysfunction that adversely impact health and wellbeing. This study will investigate the effectiveness (intention-to-treat) of a neuro-cardiac self-regulation therapy to improve autonomic and neural/brain activity in adults with SCI living in the community., Methods: A two-arm parallel, randomised controlled trial in which adults with SCI living in the community post-rehabilitation will be randomly assigned to a treatment or control group. The treatment group (N = 60) aged 18-70 years with a chronic traumatic or non-traumatic SCI, will receive intervention sessions once per week for 10 weeks, designed to regulate autonomic activity using computer-based feedback of heart rate variability and controlled breathing (called HRV-F). Comprehensive neurophysiological and psychological assessment will occur at baseline, immediate post-treatment, and 6 and 12-months post-treatment. Primary outcome measures include electrocardiography/heart rate variability (to assess autonomic nervous system function) and transcranial doppler sonography (to assess cerebral blood circulation in basal cerebral arteries). Secondary outcomes measures include continuous blood pressure, electroencephalography, functional near-infrared spectroscopy, respiration/breath rate, electrooculography, cognitive capacity, psychological status, pain, fatigue, sleep and quality of life. Controls (N = 60) will receive usual community care, reading material and a brief telephone call once per week for 10 weeks and be similarly assessed over the same time period as the HRV-F group. Linear mixed model analysis with repeated measures will determine effectiveness of HRV-F and latent class mixture modelling used to determine trajectories for primary and selected secondary outcomes of interest., Discussion: Treatments for improving autonomic function after SCI are limited. It is therefore important to establish whether a neuro-cardiac self-regulation therapy can result in improved autonomic functioning post-SCI, as well as whether HRV-F is associated with better outcomes for secondary conditions such as cardiovascular health, cognitive capacity and mental health., Trial Registration: The study has been prospectively registered with the Australian and New Zealand Clinical Trial Registry ( ACTRN12621000870853 .aspx). Date of Registration: 6th July 2021. Trial Sponsor: The University of Sydney, NSW 2006. Protocol version: 22/07/2021., (© 2021. The Author(s).)

Objective: There have been few descriptions of how outpatient cancer care is provided to patients from culturally and linguistically diverse (CALD) communities. As populations who experience disparities in cancer care access and outcomes, deeper understanding is needed to help identify those factors which can shape the receipt of multidisciplinary care in ambulatory settings. This paper reports on data collected and analysed as part of a multicentre characterisation of care in Australian public hospital cancer outpatient clinics (OPCs)., Results: Analysis of data from our ethnographic study of four OPCs identified three themes: "Identifying CALD patient language-related needs"; "Capacity and resources to meet CALD patient needs", and "Making it work for CALD communities." The care team comprises not only clinicians but also families and non-clinical staff; OPCs serve as "touchpoints" facilitating access to a range of therapeutic services. The findings highlight the potential challenges oncology professionals negotiate in providing care to CALD communities and the ways in which clinicians adapt their practices, formulate strategies and use available resources to support care delivery., (© 2021. The Author(s).)

Introduction: Value-based healthcare delivery models have emerged to address the unprecedented pressure on long-term health system performance and sustainability and to respond to the changing needs and expectations of patients. Implementing and scaling the benefits from these care delivery models to achieve large-system transformation are challenging and require consideration of complexity and context. Realist studies enable researchers to explore factors beyond 'what works' towards more nuanced understanding of 'what tends to work for whom under which circumstances'. This research proposes a realist study of the implementation approach for seven large-system, value-based healthcare initiatives in New South Wales, Australia, to elucidate how different implementation strategies and processes stimulate the uptake, adoption, fidelity and adherence of initiatives to achieve sustainable impacts across a variety of contexts., Methods and Analysis: This exploratory, sequential, mixed methods realist study followed RAMESES II (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) reporting standards for realist studies. Stage 1 will formulate initial programme theories from review of existing literature, analysis of programme documents and qualitative interviews with programme designers, implementation support staff and evaluators. Stage 2 envisages testing and refining these hypothesised programme theories through qualitative interviews with local hospital network staff running initiatives, and analyses of quantitative data from the programme evaluation, hospital administrative systems and an implementation outcome survey. Stage 3 proposes to produce generalisable middle-range theories by synthesising data from context-mechanism-outcome configurations across initiatives. Qualitative data will be analysed retroductively and quantitative data will be analysed to identify relationships between the implementation strategies and processes, and implementation and programme outcomes. Mixed methods triangulation will be performed., Ethics and Dissemination: Ethical approval has been granted by Macquarie University (Project ID 23816) and Hunter New England (Project ID 2020/ETH02186) Human Research Ethics Committees. The findings will be published in peer-reviewed journals. Results will be fed back to partner organisations and roundtable discussions with other health jurisdictions will be held, to share learnings., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Studies report rates of mild cognitive impairment (MCI) in spinal cord injury (SCI) range between 10 and 60%. This broad estimate of MCI in SCI is most likely a result of: (i) inconsistent operationalization of MCI; (ii) heterogeneity among individuals with SCI; (iii) failure to account for MCI subtypes, thereby adding to the heterogeneity of samples; and, (iv) poor control for traumatic brain injury (TBI) that obscures differentiation of MCI attributable to TBI versus other factors. There is a paucity of longitudinal studies following the course of MCI in SCI, and none that account for multiple predictors of MCI, including interactions among predictors., Methods: An inception cohort longitudinal study will assess approximately 100 individuals aged 17-80 years with acute SCI, with measures taken at three timepoints (baseline, 3 months post-baseline, and 12 months post-injury). Data relevant to medical care received within the first 24-48 h of presentation to the emergency department will be analysed, as will measures of cognition, injury characteristics, medical history, personal factors, psychological status, psychosocial functioning, and quality of life. Latent class mixture modelling will determine trajectories for the primary outcome of interest, cognitive functioning and its subtypes, and secondary outcomes of interest such as depression. Multiple regression analyses will identify predictors of MCI and its subtypes., Discussion: The prospective design will reveal change in cognitive functioning across time and unveil different outcome trajectories; thus addressing the lack of knowledge on trajectories of MCI and MCI subtypes in SCI. Through subtyping MCI, we hope to yield groups of cognitively impaired individuals with SCI that are potentially more homogenous and thereby stable and predictable. This is the first study to capture emergency department and acute care diagnostic evidence of mild TBI, which has been poorly controlled in previous studies. Our study will also be the first to distinguish the contribution of TBI from other factors to the development of MCI in individuals with SCI., Trial Registration: The study was prospectively registered with the Australian and New Zealand Clinical Trial Registry ( ACTRN12619001702101 ) on 3rd December 2019.

Objective: Organisational change in hospitals is a frequent, seemingly inevitable occurrence. A critical precursor to successful organisational change is change readiness. This paper presents the adaptation of a self-report measure of change readiness for hospital staff, examines its reliability and validity, and evaluates the relationship between hospital change readiness (HCR) and staff well-being., Methods: The questionnaire was piloted among 153 staff from a large metropolitan, public hospital in Sydney, Australia. The hospital was undergoing a major change involving a multimillion-dollar development project that included a new building and new models of care. Construct validity was evaluated by confirmatory factor analysis (CFA) and reliability was assessed by internal consistency. Differences between professional groups were examined using regression analyses and structural equation modelling (SEM) was used to test the relationship between change readiness and staff well-being (job satisfaction and burnout)., Results: The HCR Questionnaire was found to reflect theoretically derived and empirically observed domains and have high internal reliability. CFA identified that a two-factor structure demonstrated excellent fit. Cronbach's alpha for the two subscales (appropriateness and change efficacy) was 0.85 and 0.75, respectively. No statistically significant differences of HCR were identified between professional groups. SEM revealed that perceiving change as appropriate was significantly positively related to job satisfaction (0.33) and significantly negatively related to burnout (-0.30), and feeling capable in implementing the change was significantly negatively related to burnout (-0.40)., Conclusions: The HCR Questionnaire provides reliable information on how prepared hospital staff felt for organisational change and showed significant relationships with staff well-being. This questionnaire is validated for the Australian hospital context, particularly in the case of hospital redevelopment. It can be used to help manage times of hospital organisational change with minimal disruption to the quality and safety of patient care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Healthcare organisations vary in the degree to which they implement quality and safety systems and strategies. Large-scale cross-sectional studies have been implemented to explore whether this variation is associated with outcomes relevant at the patient level. The Deepening our Understanding of Quality in Australia (DUQuA) study draws from earlier research of this type, to examine these issues in 32 Australian hospitals. This paper outlines the key implementation and analysis challenges faced by DUQuA. Many of the logistical difficulties of implementing DUQuA derived from compliance with the administratively complex and time-consuming Australian ethics and governance system designed principally to protect patients involved in clinical trials, rather than for low-risk health services research. The complexity of these processes is compounded by a lack of organizational capacity for multi-site health services research; research is expected to be undertaken in addition to usual work, not as part of it. These issues likely contributed to a relatively low recruitment rate for hospitals (41% of eligible hospitals). Both sets of issues need to be addressed by health services researchers, policymakers and healthcare administrators, if health services research is to flourish. Large-scale research also inevitably involves multiple measurements. The timing for applying these measures needs to be coherent, to maximise the likelihood of finding real relationships between quality and safety systems and strategies, and patient outcomes; this timing was less than ideal in DUQuA, in part due to administrative delays. Other issues that affected our study include low response rates for measures requiring recruitment of clinicians and patients, missing data and a design that necessarily included multiple statistical comparisons. We discuss how these were addressed. Successful completion of these projects relies on mutual and ongoing commitment, and two-way communication between the research team and hospital staff at all levels. This will help to ensure that enthusiasm and engagement are established and maintained., (© The Author(s) 2020. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: An understanding of the real-world provision of oncology outpatient services can help maintain service quality in the face of escalating demand and tight budgets, by informing the design of interventions that improve the effectiveness or efficiency of provision. The aims of this study are threefold. First, to develop an understanding of cancer services in outpatient clinics by characterising the organisation and practice of multidisciplinary care (MDC). Second, to explore the key areas of: (a) clinical decision-making and (b) engagement with patients' supportive needs. Third, to identify barriers to, and facilitators of, the delivery of quality care in these settings., Methods and Analysis: A suite of mixed-methods studies will be implemented at six hospitals providing cancer outpatient clinics, with a staged roll-out. In Stage One, we will examine policies, use unstructured observations and undertake interviews with key health professionals to characterise the organisation and delivery of MDC. In Stage Two, observations of practice will continue, to deepen our understanding, and to inform two focused studies. The first will explore decision-making practices and the second will examine how staff engage with patients' needs; both studies involve interviews, to complement observation. As part of the study of supportive care, we will examine the implications of an introduction of patient-reported measures (PRMs) into care, adding surveys to interviews before and after PRMs roll-out. Data analysis will account for site-specific and cross-site issues using an adapted Qualitative Rapid Appraisal, Rigorous Analysis approach. Quantitative data from clinician surveys will be statistically analysed and triangulated with the related qualitative study findings., Ethics and Dissemination: Ethical approval was granted by South Eastern Sydney Local Health District Human Research Ethics Committee (no. 18/207). Findings will be shared with participating hospitals and widely disseminated through publications and presentations., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Background: Physical injury and psychological disorder following a motor vehicle crash (MVC) is a public health concern. The objective of this research was to determine rates of major depressive disorder (MDD) and post-traumatic stress disorder (PTSD) in adults with MVC-related injury engaged in compensation, and to determine the capacity (e.g. sensitivity and specificity) of two psychometric scales for estimating the presence of MDD and PTSD., Methods: Participants included 109 adults with MVC-related injury engaged in compensation during 2015 to 2017, in Sydney, Australia. The mean time from MVC to baseline assessment was 11 weeks. Comprehensive assessment was conducted at baseline, and the Depression Anxiety Stress Scales (DASS-21) and the Impact of Event Scale-Revised (IES-R) were administered to determine probable MDD and PTSD. An online psychiatric interview, based on Diagnostic and Statistical Manual for Mental Disorders (DSM-5), was used to diagnose actual MDD and PTSD, acknowledged as gold standard diagnostic criteria. One-way multivariate analyses of variance established criterion validity of the DASS-21 and IES-R, and sensitivity and specificity analyses were conducted to determine the most sensitive cut-off points for detecting probable MDD and PTSD., Results: Substantial rates of MDD (53.2%) and PTSD (19.3%) were found. The DASS-21 and IES-R were shown to have excellent criterion validity for detecting MDD and PTSD in injured participants. A range of cut-off points were investigated and shown to have acceptable sensitivity and specificity for detecting MDD and PTSD in an injured population engaged in compensation. The preferred cut-off points based on this study are: to detect MDD, a DASS-21 total score of 30 and/or a DASS-21 depression score of 10; to detect PTSD, IES-R scores of 33-40 and/or a DASS-21 anxiety score of 7-8., Conclusions: Major psychological disorder is prevalent following a MVC. Results suggest the DASS-21 and IES-R are suitable for use in clinical/compensation settings to detect probable MDD and PTSD soon after a MVC in physically injured people engaged in compensation. These results provide positive direction in the public health arena for improving mental health outcomes., Trial Registration: Clinical Trials registration number: ANZCTR - ACTRN12615000326594 (9th April 2015).

Objective: To conduct a prospective study of the occurrence of psychological disorders and comorbidities after spinal cord injury (SCI), determine psychotropic medication usage, and establish predictors of psychological disorders after transition to the community., Design: Longitudinal design with multiple measures., Setting: Assessment occurred in SCI units and the community., Participants: Adults with SCI (N=88) admitted over a period of 32 months into 3 SCI units., Interventions: Participants completed inpatient rehabilitation for an acute SCI. Longitudinal assessment occurred up to 6 months postdischarge., Main Outcome Measures: Measures were chosen that had a theoretical and clinical foundation for contributing to recovery after SCI. The Mini International Neuropsychiatric Interview, a structured diagnostic psychiatric interview, was conducted to determine the presence of psychological disorders. Medical measures included severity of secondary conditions or complications. Psychological measures included measures of anxiety and depressive mood, resilience, pain catastrophization, self-efficacy, and cognitive capacity., Results: Rates of psychological disorders of 17% to 25% were substantially higher than rates found in the Australian community. The occurrence of psychological disorder comorbidities was also very high. Anxiety was significantly elevated in those with a psychological disorder. Psychotropic medications were prescribed to more than 36% of the sample, with most being antidepressants. Factors predictive of psychological disorders included years of education, premorbid psychiatric/psychological treatment, cognitive impairment, secondary complications, resilience, and anxiety., Conclusions: SCI can have a substantial negative impact on mental health that does not change up to 6 months postdischarge. Findings suggest a substantial minority experience increased psychosocial distress after the injury and after transitioning into the community. Additional resources should be invested in improving the mental health of adults with SCI., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)