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Background: Although there is some qualitative research on physiotherapists' experiences of delivering low back pain treatment, we do not know the extent that these findings apply to low back pain prevention., Objective: To explore physiotherapists' understanding, attitudes and experiences related to delivering low back pain prevention programs., Design: Qualitative interview study., Method: Interviews from 25 Australian physiotherapists (56% female; 44% male) were analysed using framework thematic analysis., Results: Theme 1 explored physiotherapists' hesitancy about 'low back pain prevention,' raising concerns this term might inadvertently entrench unhelpful beliefs. They preferred language about minimising the risk and impact of recurrences, and promoting an active lifestyle. Theme 2 emphasised that as pain receded, engaging patients could be challenging. Some discussed that person-centred care and individualised programs helped overcome this challenge. Several wanted more training in counselling skills, and more consistent external messaging about low back pain prevention. Theme 3 highlighted uncertainty about delivering high-value prevention care. Some perceived the programs as potentially placing unnecessary financial burden on some patients. Many physiotherapists were uncertain about how to support patients when they weren't in pain (i.e., remission) and wanted training in tailored exercise prescription., Conclusions: Many of the physiotherapists had some hesitations and unmet needs regarding delivery of exercise programs for secondary prevention of low back pain. Clinicians may find it useful to ask patients directly about their interest in prevention programs and work with interested patients to develop tailored, progressive programs that continue to be motivating, even during periods when there is no pain., Competing Interests: Declaration of competing interest None., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Objective: To explore clinicians' and women's views and experiences with managing polycystic ovary syndrome (PCOS)., Methods: Semi-structured interviews with 36 clinicians and 26 women with PCOS. Clinicians were recruited through advertising via relevant professional organisations, snowballing and contacting clinics across Australia. Women with PCOS were recruited through social media advertising. Transcribed audio-recordings were analysed thematically using Framework analysis., Results: Findings across women with PCOS and clinician interviews were organised into three themes. Both women and clinicians experienced 1) challenges with managing PCOS, often stemming from the disparate and wide spectrum of presentations, issues with current treatment options (including limited evidence) and the long-term nature of management. Both spoke about 2) online information about PCOS and alternative treatments, including lack of relevant information and widespread misinformation. 3) Follow-up and continuity of care, where we found notable differences between women's and clinicians' expectations., Conclusions: This is the first study to explore both clinicians' and women's experiences with managing PCOS, illustrating several challenges in managing this heterogeneous condition., Practice Implications: Clarifying and addressing patient expectations, providing personalised counselling and information according to PCOS phenotype and a multidisciplinary approach may reduce uncertainty and improve patient-centred care., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective: Many older adults (aged 75+) continue cancer screening despite guidelines suggesting they should not. Using mixed-methods, we examined psychosocial and clinical factors associated with continued breast/prostate screening., Methods: We conducted an online, scenario-based, randomized study in Australia with participants aged 65+ years. The primary outcome was screening intention (10-point scale, dichotomized: low (1-5) and high (6-10)). We also measured demographic, psychosocial, and age-related clinical variables. Participants provided reason/s for their screening intentions in free-text., Results: 271 eligible participants completed the survey (aged 65-90 years, 71% adequate health literacy). Those who reported higher cancer anxiety, were men, screened more recently, had family history of breast/prostate cancer and were independent in activities of daily living, were more likely to intend to continue screening. Commonly reported reasons for intending to continue screening were grouped into six themes: routine adherence, the value of knowing, positive screening attitudes, perceived susceptibility, benefits focus, and needing reassurance., Conclusions: Psychosocial factors may drive continued cancer screening in older adults and undermine efforts to promote informed decision-making., Practice Implications: When communicating benefits and harms of cancer screening to older adults, both clinical and psychosocial factors should be discussed to support informed decision-making., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Research in health literacy is fundamentally impacted by our ability to adequately assess the construct. Although various measures of health literacy have been developed, there are few reflective discussions of the challenges and learnings from the instrument development process. This is somewhat surprising given that health literacy is a multi-dimensional and contested concept (with inherent measurement challenges), and that there are important practical considerations owing to the fact that people completing health literacy assessments may have lower general literacy (i.e. ability to read and write) and English-language skills. This paper discusses our learnings from developing a performance-based measure of parenting health literacy skills (the Parenting Plus Skills Index). The performance-based instrument is characterised by its grounding in health literacy as asset, with items spanning Nutbeam's functional, communicative and critical health literacy skills, and was designed chiefly to capture improvements resulting from health literacy skills training. This paper elucidates critical junctures in the development process, particularly regarding the conceptualisation and operationalisation of the construct. We also outline our approach to addressing practical measurement issues (e.g. administration time; item difficulty). In summarising these, we offer a 13-item checklist to inform the development of health literacy instruments for other health contexts or health conditions., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective: Existing instruments for assessing health literacy skills in parents have limited scope to inform the design and evaluation of health literacy interventions. In this study we aimed to develop and validate a new performance-based measure of health literacy for Australian parents, the Parenting Plus Skills Index (PPSI). The instrument aimed to assess functional, communicative and critical health literacy skills., Methods: The PPSI was developed in three phases: 1) Modified Delphi Expert Panel to provide feedback on 34 initial items; 2) Evaluation of psychometric properties of each item using a multidimensional item response theory model in a sample of Australian adults of parenting age (20-44 years) (N = 500); 3) Assessment of subset of items in an independent sample (N = 500)., Results: Following the three phases, 13 items were included in the final instrument. Participants scored on average 8.9/13 (69 %). The instrument demonstrated acceptable reliability (r = 0.70) and was significantly correlated with other performance-based health literacy instruments., Conclusions: The PPSI is a validated 13-item performance-based instrument that assesses health literacy skills for parents in an Australian setting., Practice Implications: The PPSI fills an important gap in available health literacy instruments that may be useful for facilitating development and evaluation of health literacy interventions., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: Limited examples exist globally of coordinated, organisation-wide health literacy approaches to systematically improve the understandability and actionability of patient health information. Even fewer have been formally evaluated. The aim of this study was to use the Patient Education Materials Assessment Tool (PEMAT) to evaluate the effectiveness of an organisation-wide, evidence-based approach to improve the understandability and actionability of patient information materials in regional health service in New South Wales, Australia., Methods: Two independent raters (blinded to the document version) evaluated pre- and post-implementation versions of 50 randomly-selected patient information materials using the PEMAT, with differences in understandability and actionability analysed using paired samples tests., Results: Mean (±SD) overall scores for understandability increased significantly by 5% (95% CI 2-8; p = 0.002) up to 77%±10%, and mean actionability (±SD) increased significantly by 4% (95% CI 0-8; p = 0.046) up to 56%±22%., Conclusion: These results demonstrate that organisation-wide approaches with standardised processes for staff to prepare, review and store written patient information and education materials can be successfully implemented to address the impacts and risks of low health literacy., Practice Implications: The success of this approach provides a framework for other health organisations to work in partnership with patients to make health information more understandable and actionable., (Copyright © 2019. Published by Elsevier B.V.)

Background: Of the available treatment options for attention-deficit/hyperactivity disorder (ADHD), the use of medications remains the most controversial and it is often difficult for parents to make decisions about treatment. Provision of relevant, reliable information about treatment during consultations may help address parents' concerns about treatment options. Question prompt lists are structured lists of disease and treatment-specific questions intended for use by patients during consultations to encourage communication with clinicians. They may prove useful in empowering parents to ask questions during consultations and to make informed decisions about treatments for ADHD., Objectives: To evaluate the acceptability and usefulness of a question prompt list (QPL) for attention-deficit/hyperactivity disorder (ADHD) during consultations between parents of diagnosed children and their pediatricians., Methods: Parents of children recently diagnosed with ADHD (n = 17) received a copy of the QPL 7 days before their child's appointment and completed questionnaires before and after their consultations to elicit: satisfaction with the consultation and QPL; situational anxiety levels; achievement of decision-making and information preferences. Pediatricians (n = 3) completed questionnaires after each consultation to determine the impact of the QPL on consultation flow and to ascertain their willingness to incorporate the QPL into their practice., Results: All parents reported that the QPL helped them to ask more questions, was easy to understand and would be useful to them in future. After receiving the QPL and seeing the pediatrician, parents' anxiety decreased significantly. All described their decision-making roles as 'just right' and were satisfied with the information obtained during their consultations. All pediatricians agreed that the QPL was helpful for parents, made communication easier, and helped parents to initiate discussion about difficult topics. The QPL was not found to impede flow of the consultation. All agreed QPL provision was feasible as part of routine clinical care., Conclusions: The QPL received strong support from parents and pediatricians and may be a useful tool in facilitating communication and shared decision-making in this setting. The findings warrant further investigation in a larger randomized controlled study., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Study Objective: The main objective of the current investigation was to assess the readability of Internet-based patient education materials related to the field of anesthesiology. We hypothesized that the majority of patient education materials would not be written according to current recommended readability grade level., Setting: Online patient education materials describing procedures, risks, and management of anesthesia-related topics were identified using the search engine Google (available at www.google.com) using the terms anesthesia, anesthesiology, anesthesia risks, and anesthesia care., Design: Cross-sectional evaluation., Interventions: None., Measurements: Assessments of content readability were performed using validated instruments (Flesch-Kincaid Grade Formulae, the Gunning Frequency of Gobbledygook, the New Dale-Chall Test, the Fry graph, and the Flesch Reading Ease score)., Main Results: Ninety-six Web sites containing Internet patient education materials (IPEMs) were evaluated. The median (interquartile range) readability grade level for all evaluated IPEMs was 13.5 (12.0-14.6). All the evaluated documents were classified at a greater readability level than the current recommended readability grade, P < .001. Readability grades were not significantly different among different IPEM sources. Assessment by the Flesch Reading Ease test classified all but 4 IPEMs as at least fairly difficult to read., Conclusions: Internet-based patient education materials related to the field of anesthesiology are currently written far above the recommended readability grade level. High complexity of written education materials likely limits access of information to millions of American patients. Redesign of online content of Web sites that provide patient education material regarding anesthesia could be an important step in improving access to information for patients with poor health literacy., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To examine the effects of communicating uncertainty in quantitative health risk estimates on participants' understanding, risk perception and perceived credibility of risk information source., Methods: 120 first year psychology students were given a hypothetical health-care scenario, with source of risk information (clinician, pharmaceutical company) varied between subjects and uncertainty (point, small range and large range risk estimate format) varied within subjects., Results: The communication of uncertainty in the form of both a small and large range resulted in a reduction in accurate understanding and increased perceptions of risk when a large range was communicated compared to a point estimate. It also reduced perceptions of credibility of the information source, though for the clinician this was only the case when a large range was presented., Conclusions: The findings suggest that even for highly educated adults, communicating uncertainty as a range risk estimate has the potential to negatively affect understanding, increase risk perceptions and decrease perceived credibility., Practice Implications: Communicating uncertainty in risk using a numeric range should be carefully considered by health-care providers. More research is needed to develop alternative strategies to effectively communicate the uncertainty in health risks to consumers., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objective: To describe a theoretical framework for assessing knowledge about the possible outcomes of participating in bowel cancer screening for the faecal occult blood test., Methods: The content of the knowledge measure was based on the UK General Medical Council's screening guidelines and a theory-based approach to assessing gist knowledge (Fuzzy Trace Theory). It comprised conceptual and numeric questions to assess knowledge of the underlying construct (e.g. false positive concept) and the approximate numbers affected (e.g. likelihood of a false positive). The measure was used in a randomised controlled trial involving 530 adults with low education, to compare the impact of a bowel screening decision aid with a screening information booklet developed for the Australian Government National Bowel Cancer Screening Program., Results: The numeric knowledge scale was particularly responsive to the effects of the decision aid; at follow-up decision aid participants' numeric knowledge was significantly greater than the controls (P<0.001). This contrasts with the conceptual knowledge scale which improved significantly in both groups from baseline to follow-up (P<0.001)., Conclusion: Our theory-based knowledge measure was responsive to change in conceptual knowledge and to the effect on numeric knowledge of a decision aid., Practice Implications: This theoretical framework has the potential to guide the development of knowledge measures in other screening settings., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

The routine use of pre-operative MRI in women with newly diagnosed breast cancer highlights the complexities of the use of new technology when evidence of benefit is uncertain. There are both potential harms and benefits. In the short term patients may desire and feel reassured by further testing and the use of new diagnostic techniques. However, they may also experience greater anxiety and distress from further tests and related follow-up procedures such as biopsy. In the long term MRI may result in more radical treatment decisions which are associated with poorer quality of life for women. Both patients and clinicians often (wrongly) assume that more information via testing leads to better outcomes (information bias). So how should pre-operative MRI be integrated into breast cancer care? First women need to be made aware of the uncertain evidence surrounding MRI. However whether it is appropriate to burden women with complex information and yet another decision at a time of high vulnerability and emotional distress should be considered. One potential solution is to use a Community Informed Consent approach in which a representative sample of patients and healthy women are educated about the benefits and harms and give their informed opinion about whether pre-operative MRI should be offered. Another approach is to provide patients with an evidence based decision aid to support individual informed choice. Either or a combination of both approaches would be acceptable and should be investigated. At present women are poorly informed about pre operative MRI and it is likely that they assume outcomes are be improved as a result. Clear communication about the limits of MRI to patients is needed alongside randomised trials to provide the evidence that benefit indeed outweighs the harms so that all parties involved may be comprehensively informed., (Copyright (c) 2009 Elsevier Ltd. All rights reserved.)

Objective: Several countries have recently implemented national bowel cancer screening programs. To ensure equal access to screening, information is needed to suit adults ranging in literacy level. Decision aids are effective in providing balanced information and have been applied in screening. However, few have been designed for populations with lower education and literacy. This article describes the development and preliminary evaluation of a bowel cancer screening decision aid for this group., Method: We conducted face-to-face interviews with adults of varying literacy ability, to develop the decision aid (Stage 1). We applied principles of plain language, created visual illustrations to support key textual messages, and used colour coding to direct the reader through the booklet. We then explored its acceptability and comprehension among consumers with higher and lower education (Stage 2). Participants were recruited from a community sample with lower education and a university alumni network., Results: A total of 75 participants were interviewed, 43 with lower educational attainment and 32 with university education. The decision aid was positively reviewed by both education groups. Results highlighted the need to clarify the purpose of the decision aid and the availability of choice in the context of screening, especially to those with lower education., Conclusion: The 2 stage iterative development process identified important factors to consider in the development of decision tools for this target group, and is recommended., Practice Implications: Our findings have implications for how to support people with lower education and literacy make informed screening decisions.

Objective: To examine women's informed preference for the management of a mildly abnormal Pap smear and the impact of a decision aid., Methods: Women (n=106) were given a choice of management supported by a decision aid and surveyed before, and after decision making to evaluate predictors of choice and decision aid impact., Results: HPV triage was preferred by most women (65%) although a substantial minority selected repeat Pap testing (35%). Women who chose HPV triage were more likely to have had children, have had a previous abnormal Pap smear and were more distressed than women who chose a repeat Pap test. In total, 68% of women made an informed choice. Rapid timing of follow-up was important for women choosing HPV testing. The lower chance of colposcopy and greater opportunity for regression, were rated as important by women choosing Pap testing. Decisional conflict was lower among women who chose HPV triage. No other differences in short-term psychological outcomes were found., Conclusion: The decision aid supported informed choice among the majority of women. Women tailored their choice to their practical, health and psychological needs., Practice Implications: Offering women an informed choice for a mildly abnormal Pap smear may enable women to select the management that best suits their circumstances.